The robotic surgical system has been applied in liver surgery. However, controversies concerns exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness ...of robotic surgery. To promote the development of robotic hepatectomy, this study aimed to evaluate the current status of robotic hepatectomy and provide sixty experts' consensus and recommendations to promote its development. Based on the World Health Organization Handbook for Guideline Development, a Consensus Steering Group and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 22 topics were prepared analyzed and widely discussed during the 4 meetings. Based on the published articles and expert panel opinion, 7 recommendations were generated by the GRADE method using an evidence-based method, which focused on the safety, feasibility, indication, techniques and cost-effectiveness of hepatectomy. Given that the current evidences were low to very low as evaluated by the GRADE method, further randomized-controlled trials are needed in the future to validate these recommendations.
Abstract Background There is no comparative analysis of the learning curves for robot-assisted and laparoscopic liver resection. We aimed to compare learning curves in complex robotic and ...conventional laparoscopic liver resections with regards to estimation of the difficulty index score. Methods The results of 131 consecutive liver resections were analyzed retrospectively (40 robot-assisted and 91 laparoscopic). The learning curve evaluation was based on calculation of procedures number before significant change of the difficulty index for minimally invasive liver resection or the rate of posterosuperior segments resection. Groups of early and late experience were compared in every type of approach (robot-assisted and laparoscopic). Results Significant increase of difficulty index (from 5.0 3.0–7.7 to 7.3 4.3–10.2) of robotic procedures required 16 procedures. It was necessary to perform 29 laparoscopic resections in order to significantly increase the rate of laparoscopic posterosuperior segments resection but without significant increase of difficulty index. The implementation of minimally invasive liver resection started with the robotic approach. Conclusion The learning curve for robot-assisted liver resections is shorter in comparison with laparoscopic resections. The inclusion of robot-assisted resections in a minimally invasive liver surgery program may be useful to rapidly increase the complexity of laparoscopic liver resections.
Minimally invasive right posterior sectionectomy (RPS) is a technically challenging procedure. This study was designed to determine outcomes following robotic RPS (R-RPS) and laparoscopic RPS ...(L-RPS).
An international multicentre retrospective analysis of patients undergoing R-RPS versus those who had purely L-RPS at 21 centres from 2010 to 2019 was performed. Patient demographics, perioperative parameters, and postoperative outcomes were analysed retrospectively from a central database. Propensity score matching (PSM) was performed, with analysis of 1 : 2 and 1 : 1 matched cohorts.
Three-hundred and forty patients, including 96 who underwent R-RPS and 244 who had L-RPS, met the study criteria and were included. The median operating time was 295 minutes and there were 25 (7.4 per cent) open conversions. Ninety-seven (28.5 per cent) patients had cirrhosis and 56 (16.5 per cent) patients required blood transfusion. Overall postoperative morbidity rate was 22.1 per cent and major morbidity rate was 6.8 per cent. The median postoperative stay was 6 days. After 1 : 1 matching of 88 R-RPS and L-RPS patients, median (i.q.r.) blood loss (200 (100-400) versus 450 (200-900) ml, respectively; P < 0.001), major blood loss (> 500 ml; P = 0.001), need for intraoperative blood transfusion (10.2 versus 23.9 per cent, respectively; P = 0.014), and open conversion rate (2.3 versus 11.4 per cent, respectively; P = 0.016) were lower in the R-RPS group. Similar results were found in the 1 : 2 matched groups (66 R-RPS versus 132 L-RPS patients).
R-RPS and L-RPS can be performed in expert centres with good outcomes in well selected patients. R-RPS was associated with reduced blood loss and lower open conversion rates than L-RPS.
Background
The diffusion of laparoscopic radical surgery for hydatid liver echinococcosis remains limited. There are no published data on a comparative analysis of the immediate and long-term results ...of radical and conservative laparoscopic surgery for liver hydatid cysts. Comparison of the immediate and long-term outcomes after laparoscopic radical and conservative cystectomies was aimed.
Methods
HPB center (Center 1) and general surgery hospital in an endemic area (Center 2) participated in a retrospective study. Radical surgery included total, subtotal pericystectomy, and liver resection. Conservative surgery comprised cystectomy without/with partial pericystectomy.
Results
The total number of patients who underwent surgery for liver hydatid cysts was 213. Laparoscopic cystectomy was performed in 106 (50%) patients. This number included 47 radical laparoscopic cystectomy (Center 1). Conservative laparoscopic procedures were used in 59 patients (Center 2). Finally, twenty-seven pairs of patients were matched. Immediate outcomes were better for radical treatment in terms of severe morbidity, length of hospital stay, and time of abdominal drainage before and after PSM. The mean follow-up length was 23 (4–66) and 29 (6–66) months and the recurrence rate was 2% and 5% in groups of radical and conservative treatment respectively. No differences were found in 1-, 3-, and 5-year disease free survival. After second PSM for recurrence, 20 pairs were matched with no relapse of disease.
Conclusion
Laparoscopic radical surgery leads to the better immediate outcomes and can be recommended as the preferred treatment option in a specialized HPB center. Conservative option is justified in general hospitals in endemic area for selected uncomplicated cysts.
An antenna array with short shielded transverse electromagnetic horns (S-TEM-horns) for emitting high-power radiation of ultra-short electromagnetic pulses (USEMP) has been created and researched. ...The antenna unit consists of an ultra-wideband antenna array with four S-TEM horns, with each connected to a two-wire HF transmission line, and these four lines are connected to an antenna feeder. This feeder is connected to a semiconductor generator with the following parameters: a 50 Ohm connector, 10–100 kV high-voltage monopolar pulses, a rise time of about 0.1 ns, FWHM = 0.2–1 ns, and pulse repetition rates of 1–100 kHz. The antenna array was designed and optimized to achieve a high efficiency of about 100% for the antenna aperture by using a 2 × 2 array with S-TEM-horns, with shielding rectangular plates for the return current. The transient responses were studied by simulation using the electromagnetic 3D code “KARAT” at the time domain and experimentally with the use of our stripline sensor for measurement of the impulse electrical field with a 0.03 ns rise time and a 7 ns duration at the traveling wave. The radiators were emitting USEMP waves with a hyperband frequency spectrum of 0.1–6 GHz. The radiation with an amplitude of 5–30 kV/m of the E-field strength at a distance of up to 20 m was successfully applied to test the electronics for immunity to electromagnetic interference.
A shift towards parenchymal-sparing liver resections in open and laparoscopic surgery emerged in the last few years. Laparoscopic liver resection is technically feasible and safe, and consensus ...guidelines acknowledge the laparoscopic approach in the posterosuperior segments. Lesions situated in these segments are considered the most challenging for the laparoscopic approach. The aim of this trial is to compare the postoperative time to functional recovery, complications, oncological safety, quality of life, survival and costs after laparoscopic versus open parenchymal-sparing liver resections in the posterosuperior liver segments within an enhanced recovery setting.
The ORANGE Segments trial is an international multicentre randomised controlled superiority trial conducted in centres experienced in laparoscopic liver resection. Eligible patients for minor resections in the posterosuperior segments will be randomised in a 1:1 ratio to undergo laparoscopic or open resections in an enhanced recovery setting. Patients and ward personnel are blinded to the treatment allocation until postoperative day 4 using a large abdominal dressing. The primary endpoint is time to functional recovery. Secondary endpoints include intraoperative outcomes, length of stay, resection margin, postoperative complications, 90-day mortality, time to adjuvant chemotherapy initiation, quality of life and overall survival. Laparoscopic liver surgery of the posterosuperior segments is hypothesised to reduce time to functional recovery by 2 days in comparison with open surgery. With a power of 80% and alpha of 0.04 to adjust for interim analysis halfway the trial, a total of 250 patients are required to be randomised.
The ORANGE Segments trial is the first multicentre international randomised controlled study to compare short- and long-term surgical and oncological outcomes of laparoscopic and open resections in the posterosuperior segments within an enhanced recovery programme.
ClinicalTrials.gov NCT03270917 . Registered on September 1, 2017. Before start of inclusion.
version 12, May 9, 2017.
The Russian consensus on exo- and endocrine pancreatic insufficiency after surgical treatment was prepared on the initiative of the Russian Pancreatic Club using the Delphi method. Its goal was to ...consolidate the opinions of national experts on the most relevant issues of diagnosis and treatment of exo- and endocrine insufficiency after surgical interventions on the pancreas. An interdisciplinary approach is ensured by the participation of leading gastroenterologists and surgeons.
Textbook outcome (TO) is a composite measure that captures the most desirable surgical outcomes as a single indicator, yet to date TO has not been defined and assessed in the field of laparoscopic ...liver resection (LLR) and open liver resection (OLR).
To obtain international agreement on the definition of TO in liver surgery (TOLS) and to assess the incidence of TO in LLR and OLR in a large international multicenter database using a propensity-score matched analysis.
Patients undergoing LLR or OLR for all liver diseases between January 2011 and October 2019 were analyzed using a large international multicenter liver surgical database. An international survey was conducted among all members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA) to reach agreement on the definition of TOLS. The rate of TOLS was assessed for LLR and OLR before and after propensity-score matching. Factors associated with achieving TOLS were investigated.
Textbook outcome, with TOLS defined as the absence of intraoperative incidents of grade 2 or higher, postoperative bile leak grade B or C, severe postoperative complications, readmission within 30 days after discharge, in-hospital mortality, and the presence of R0 resection margin.
A total of 8188 patients (4559 LLR; median age, 65 years interquartile range, 55-73 years; 2529 were male 55.8% and 3629 OLR; median age, 64 years interquartile range, 56-71 years; 2204 were male 60.7%) were included in the analysis of whom 69.1% achieved TOLS; 74.8% for LLR and 61.9% for OLR (P < .001). On multivariable analysis, American Society of Anesthesiologists grade III, previous abdominal surgery, histological diagnosis of colorectal liver metastases (odds ratio OR, 0.656 95% CI, 0.457-0.940; P = .02), cholangiocarcinoma, non-CRLM, a tumor size of 30 mm or more, minor resection of posterior/superior segments (OR, 0.716 95% CI, 0.577-0.887; P = .002), anatomically major resection (OR, 0.579 95% CI, 0.418-0.803; P = .001), and nonanatomical resection (OR, 0.612 95% CI, 0.476-0.788; P < .001) were associated with a worse TOLS rate after LLR. For OLR, only histological diagnosis of cholangiocarcinoma (OR, 0.360 95% CI, 0.214-0.607; P < .001) and a tumor size of 30 mm or more (30-50 mm = OR, 0.718 95% CI, 0.565-0.911; P = .01; 50.1-100 mm = OR, 0.729 95% CI, 0.554-0.960; P = .02; >10 cm = OR, 0.550 95% CI, 0.366-0.826; P = .004) were associated with a worse TOLS rate.
In this multicenter study, TOLS was found to be a useful tool for assessing patient-level hospital performance and may have utility in optimizing patient outcomes after LLR and OLR.
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