Perihilar cholangiocarcinoma (Klatskin tumor) is one of the most challenging hepatobiliary cancers to treat due to its critical location and tendency to involve nearby vascular structures in the ...portal hepatic. A combined biliary and major liver resection is often required to achieve a complete oncological resection. Traditionally, Klatskin tumor resection is performed using an “open” approach until recently when the minimally invasive technique becomes popular due to its proven advantages. The laparoscopic technique had been reported; however, the majority of resections were types I and II without the need for ipsilateral hepatectomy. Inherent limitations of straight laparoscopic instruments result in significant technical difficulties in performing precise tissue dissection and vessel repair and creating a fine bilioenteric anastomosis. In this didactical video, we described our technique of type IIIB Klatskin tumor (B3-L perihilar cholangiocarcinoma) resection utilizing a robotic technology. The use of a robotic platform facilitates precise porta hepatic dissection, bleeding control, and creation of a fine bilioenteric anastomosis at the level of the hilar plate. We believe that the robotic platform provides an alternative method for resection of perihilar cholangiocarcinoma with excellent short-term outcomes.
The safety of major hepatectomy is determined by various preoperative and intraoperative factors; however, adequate function of the remaining part of the liver (future liver remnant (FLR)) after ...resection remains the most important indicator for posthepatectomy survival.1-4 Posthepatectomy liver failure is a fatal complication with very limited salvage option. Future liver remnant volume can be studied using several methods such as computer volumetric measurement as a surrogate marker for parenchymal function, the indocyanine green elimination test at 15 minutes, and the galactose clearance test. A bedside assistant surgeon stood to the patient’s right utilizing laparoscopic instruments to facilitate dynamic exposure and suctioning as appropriate and ultimately extracted the specimen out of the abdomen upon completion.
When the hepatic cyst causes significant hepatic enlargement, signs and symptoms such as shortness of breath, early satiety, esophageal reflux, chronic back pain, hepatic venous outflow obstruction, ...portal vein and inferior vena cava compression, as well as obstructive jaundice from bile duct compression can occur.2-4 A small percentage of patients with extreme cases even develop liver parenchymal dysfunction requiring liver transplantation. 3 Open partial hepatic resection combined with cyst fenestration/unroofing are the traditional approach to treat large symptomatic hepatic cysts with sustainable long-term outcomes. A bedside assistant surgeon stood to the patient right utilizing laparoscopic instruments to facilitate dynamic exposure and suctioning as appropriate and ultimately extracted the specimen out of the abdomen upon completion. Supplemental Material SAGE-Journals-Accessible-Video-Player 10.1177/0003134820956356.M1 sj-vid-1-asu-10.1177_0003134820956356 Robotic Unroofing of Giant Hepatic Cyst Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
In general, the presence of a communication with the bile duct is indicative of IPMN-B, while the presence of an ovarian-like stroma is consistent with MCN-L.1-4 The standard of care for treating ...this disease is a complete resection with clear margins with or without the need for biliary reconstruction. The preoperative diagnosis of MCN-L on cross-sectional imaging can be subtle and confused with benign simple hepatic cyst, which leads to the possibility of treatment error. Simple suture repair should be performed when bile leak is found indicating communication of the cystic neoplasm with the biliary tree. Besides a single case of malignancy, all other cases showed low-to-intermediate grade dysplasia.
Introduction
Most of the literature has only reported outcomes on robotic minor non-anatomical hepatectomy. This study was undertaken to analyze and examine the safety, feasibly, and perioperative ...outcomes of robotic major hepatectomy at our institution.
Methods
All patients undergoing robotic major hepatectomy were prospectively followed. Major hepatectomy was defined as a resection of 3 or more segments. Data are expressed as median (mean ± SD).
Results
A total of 170 consecutive patients underwent robotic hepatectomies, of which 100 were major resections involving at least 3 segments. The 100 patients were of median 62 (61 ± 13.0) years, and 46% were women. Median BMI was 29 (29 ± 5.9) kg/m
2
and median ASA class was 3 (3 ± 0.5). Thirty percent of robotic major hepatectomies were for hepatocellular carcinoma, 28% were for metastatic adenocarcinoma, 9% were for cholangiocarcinoma, and 5% were for metastatic neuroendocrine tumor. Prep time (in the room until incision) was a median 58 min (62 ± 18.4), extraction time (incision until specimen extraction) was 124 min (146 ± 99.5), console time was 198 min (210 ± 123.9), closure time (extraction until dressing placement) was 109 min (131 ± 93.8), operative duration was 246 min (269 ± 123.2), and time under anesthesia was 330 min (353 ± 109.6). Estimated blood loss was 175 ml (249 ± 275.9) and length of stay was 4 days (5 ± 4.3). Seven patients experienced postoperative complications. Thirteen patients were readmitted within 30 days, and one patient died within 30 days.
Conclusion
Application of the robotic platform to major hepatectomy is safe and feasible. Our early experience shows that this minimally invasive approach results in excellent short-term outcomes.
Background and Objectives
We aimed to describe our outcomes of robotic resection for perihilar cholangiocarcinoma, the largest single institutional series in the Western hemisphere to date.
Methods
...Between 2016 and 2022, we prospectively followed all patients who underwent robotic resection for perihilar cholangiocarcinoma.
Results
In total, 23 patients underwent robotic resection for perihilar cholangiocarcinoma, 18 receiving concomitant hepatectomy. The median age was 73 years. Operative time was 470 min with an estimated blood loss of 150 mL. No intraoperative conversions to open or other intraoperative complications occurred. Median length of stay was 5 days. Four postoperative complications occurred. Three readmissions occurred within 30 days with one 90‐day mortality. R0 resection was achieved in 87% of patients and R1 in 13% of patients. At a median follow‐up of 27 months, 15 patients were alive without evidence of disease, two patients with local recurrence at 1 year, and six were deceased.
Conclusions
Utilization of the robotic platform for perihilar cholangiocarcinoma is safe and feasible with excellent perioperative outcomes. Further studies are needed to determine the long‐term oncological outcomes.
Key take‐aways
Robotic resection of perihilar cholangiocarcinoma is safe and effective when performed by experienced minimally invasive hepatobiliary surgeons in a population of carefully chosen patients.
This institution series of robotically assisted resection of perihilar cholangiocarcinoma from a high‐volume minimally invasive hepatobiliary program demonstrates excellent perioperative outcomes while achieving a shorter length of stay than what has been previously reported in the literature.
The dissemination of robotic liver surgery is slow-paced and must face the obstacle of demonstrating advantages over open and laparoscopic (LLS) approaches. Our objective was to show the current ...position of robotic liver surgery (RLS) worldwide and to identify if improved short-term outcomes are observed, including secondary meta-analyses for type of resection, etiology, and cost analysis.
A PRISMA-based systematic review was performed to identify manuscripts comparing RLS vs open or LLS approaches. Quality analysis was performed using the Newcatle-Ottawa score. Statistical analysis was performed after heterogeneity test and fixed- or random-effect models were chosen accordingly.
After removing duplications, 2728 RLS cases were identified from the final set of 150 manuscripts. More than 75% of the cases have been performed on malignancies. Meta-analysis from the 38 comparative reports showed that RLS may offer improved short-term outcomes compared to open procedures in most of the variables screened. Compared to LLS, some advantages may be observed in favour of RLS for major resections in terms of operative time, hospital stay and rate of complications. Cost analyses showed an increased cost per procedure of around US$5000.
The advantages of RLS still need to be demonstrated although early results are promising. Advantages vs open approach are demonstrated. Compared to laparoscopic surgery, minor perioperative advantages may be observed for major resections although cost analyses are still unfavorable to the robotic approach.
Iatrogenic bile duct injury is a catastrophic complication during a laparoscopic cholecystectomy for biliary diseases, which occurs in less than 1% of patients in the current era.1-4 For decades, ...operative repair for bile duct injury has been traditionally performed using an “open” roux-en-y hepaticojejunostomy (HJ) via midline laparotomy or right subcostal approach. The use of robotic platform allows for application of minimally invasive techniques with superior 3-dimentional visualization, stable platform, high manual dexterity, tremor filtration, ease of dissection, and better ability to reach difficult locations. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
In most tertiary hepatobiliary and transplant centers, these operations are performed using the traditional “open” method. 1 With the advent of robotic technology, biliary surgery can now be ...performed minimally invasively with relative ease. Discussion about robotic biliary surgery is emerging in the literature, however, this innovation is only seen limitedly in a very few centers in the United States.2-4 A detailed technical description of robotic biliary surgery is nonexistent to date. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The advent of robotic technology allows for further refinement of minimally invasive techniques in liver surgery with 3-dimensionalvisualization, stable platform, high manual dexterity, tremor ...filtration, ease of suturing, and better ability to reach posterior-superior lesions, compared to the conventional laparoscopy.3,4 Being the newest technology, a detailed technical description of robotic anatomical hepatectomy using a multimedia video support is very limited. The left lobe of the liver was elevated cephalad using a robotic bowel grasper to expose the gastrohepatic ligament. A 60-mm laparoscopic EndoGIA™ linear stapler (Medtronic, Minneapolis, Minnesota, USA) was then applied by the bedside assistant to transect the portal pedicle of segments 2 and 3 in an enblock fashion (artery, portal vein, and bile duct).
