• Humans
• Hepatectomy/methods
• Liver Neoplasms/secondary
• Liver Neoplasms/surgery
• Colorectal Neoplasms/pathology
• Laparoscopy/methods
• Male
• Female
• Portal Vein/surgery
• Embolization, Therapeutic/methods
• Retrospective Studies
• Middle Aged
• Aged
• Propensity Score
• Treatment Outcome
• Feasibility Studies
• Length of Stay

• Colorectal liver metastases (CRLMs)
• laparoscopic liver resection
• minimally invasive surgery
• win ratio

• atezolizumab plus bevacizumab
• conversion surgery
• hepatocellular carcinoma
• pathological complete response
• robotic liver resection

• Humans
• Hepatectomy/adverse effects
• Robotic Surgical Procedures/adverse effects
• Cohort Studies
• Retrospective Studies
• Liver
• Liver Neoplasms/secondary
• Laparoscopy/adverse effects
• Postoperative Complications/etiology
• Surgeons
• Length of Stay
• Treatment Outcome

• CRLM
• HCC
• colorectal cancer liver metastasis
• hepatocellular carcinoma
• laparoscopic hepatectomy
• laparoscopic liver resection
• open liver resection

• liver
• minimally invasive
• robotic surgery
• surgery

Introduction

Although there are a number of benefits to using robotics in liver surgery over conventional open and laparoscopic approaches, liver parenchymal transection is still the most difficult aspect of robotic liver resection (RLR) due to the limitations of the currently available robotic instruments and the lack of a standardized method.

Methods

We present a novel method for transecting the liver parenchyma during RLR employing saline-linked monopolar cautery (SLiC) scissors (SLiC-Scissors method). Between September 2021 and April 2022, 10 RLRs were performed utilizing the SLiC-Scissors method for both anatomical and non-anatomical liver resections. We assessed the short-term results, as well as the safety and practicality of our robotic liver parenchymal transection technique.

Results

Six of the 10 patients had malignant liver tumors, and four of them had liver metastases from colorectal cancer. Except for S1, the target lesions were present everywhere, and their median size was 25 mm (14-43 mm). The median amount of intraoperative bleeding was 5 mL (5-30 mL), and the median operative and console times were 223 and 134 min, respectively. There were no conversions to open liver resections. The median length of the postoperative stay was seven (4-13) days, and there were no serious postoperative complications or mortality.

Conclusions

The SLiC-Scissors method is a safe and practical procedure for liver parenchymal transection in RLR. In order to standardize and broadly implement RLR into normal patient treatment, this unique approach enables an advanced, locally controlled preparation of intrahepatic vessels and bile ducts.

At present, there is no perfect system to evaluate pulmonary complications of liver surgery using perioperative variables.

To design and verify a risk assessment system for predicting postoperative pulmonary complications (PPCs) after hepatectomy based on perioperative variables.

A retrospective analysis was performed on 1633 patients who underwent liver surgery. The variables were screened using univariate and multivariate analyses, and graded scores were assigned to the selected variables. Logistic regression was used to develop the liver operation pulmonary complication scoring system (LOPCSS) for the prediction of PPCs. The LOPCSS was verified using the receiver operating characteristic curve.

According to the multivariate correlation analysis, the independent factors which influenced PPCs of liver surgery were age [≥ 65 years old/< 65 years old, odds ratio (OR) = 1.926, P = 0.011], medical diseases requiring drug treatment (yes/no, OR = 3.523, P < 0.001), number of liver segments to be removed (≥ 3/≤ 2, OR = 1.683, P = 0.002), operation duration (≥ 180 min/< 180 min, OR = 1.896, P = 0.004), and blood transfusion (yes/no, OR = 1.836, P = 0.003). The area under the curve (AUC) of the LOPCSS was 0.742. The cut-off value of the expected score for complications was 5. The incidence of complications in the group with ≤ 4 points was significantly lower than that in the group with ≥ 6 points (2.95% vs 33.40%, P < 0.001). Furthermore, in the validation dataset, the corresponding AUC of LOPCSS was 0.767.

As a novel and simplified assessment system, the LOPCSS can effectively predict PPCs of liver surgery through perioperative variables.

• Liver surgery
• Complication
• Pulmonary
• Prediction

• hepatocellular carcinoma
• laparoscopic liver resection
• review

• Carcinoma, Hepatocellular/surgery
• Hepatectomy
• Humans
• Laparoscopy
• Length of Stay
• Liver Neoplasms/surgery
• Neoplasm Recurrence, Local
• Postoperative Complications
• Treatment Outcome

Background: The implementation of robotics in liver surgery offers several advantages compared to conventional open and laparoscopic techniques. One major advantage is the enhanced degree of freedom at the tip of the robotic tools compared to laparoscopic instruments. This enables excellent vessel control during inflow and outflow dissection of the liver. Parenchymal transection remains the most challenging part during robotic liver resection because currently available robotic instruments for parenchymal transection have several limitations and there is no standardized technique as of yet. We established a new strategy and share our experience. Methods: We present a novel technique for the transection of liver parenchyma during robotic surgery, using three devices (3D) simultaneously: monopolar scissors and bipolar Maryland forceps of the robot and laparoscopic-guided waterjet. We collected the perioperative data of twenty-eight patients who underwent this procedure for minor and major liver resections between February 2019 and December 2020 from the Magdeburg Registry of minimally invasive liver surgery (MD-MILS). Results: Twenty-eight patients underwent robotic-assisted 3D parenchyma dissection within the investigation period. Twelve cases of major and sixteen cases of minor hepatectomy for malignant and non-malignant cases were performed. Operative time for major liver resections (≥ 3 liver segments) was 381.7 (SD 80.6) min vs. 252.0 (70.4) min for minor resections (p < 0.01). Intraoperative measured blood loss was 495.8 (SD 508.8) ml for major and 256.3 (170.2) ml for minor liver resections (p = 0.090). The mean postoperative stay was 13.3 (SD 11.1) days for all cases. Liver surgery-related morbidity was 10.7%, no mortalities occurred. We achieved an R0 resection in all malignant cases. Conclusions: The 3D technique for parenchyma dissection in robotic liver surgery is a safe and feasible procedure. This novel method offers an advanced locally controlled preparation of intrahepatic vessels and bile ducts. The combination of precise extrahepatic vessel handling with the 3D technique of parenchyma dissection is a fundamental step forward to the standardization of robotic liver surgery for teaching purposing and the wider adoption of robotic hepatectomy into routine patient care.

• hepatectomy
• hepatocellular carcinoma
• liver metastasis
• liver surgery
• robotic surgery

• Carcinoma, Hepatocellular/surgery
• Hepatectomy
• Humans
• Laparoscopy
• Length of Stay
• Liver Neoplasms/surgery
• Retrospective Studies
• Robotic Surgical Procedures

Although surgical resection is associated with the best long-term outcomes for neuroendocrine liver metastases (NELM), the current indications for and outcomes of surgery for NELM from a population perspective are not well understood.

To determine the current indications for and outcomes of liver resection (LR) for NELM using a population-based cohort.

A retrospective review of the 2014-2017 American College of Surgeons National Surgical Quality Improvement Program and targeted hepatectomy databases was performed to identify patients who underwent LR for NELM. Perioperative characteristics and 30-d morbidity and mortality were analyzed.

Among 669 patients who underwent LR for NELM, the median age was 60 (interquartile range: 51-67) and 51% were male. While the number of metastases resected ranged from 1 to 9, the most common (45%) number of tumors resected was one. The majority (68%) of patients had a largest tumor size of < 5 cm. Most patients underwent partial hepatectomy (71%) while fewer underwent a right or left hepatectomy or trisectionectomy. The majority of operations were open (82%) versus laparoscopic (17%) or robotic (1%). In addition, 30% of patients underwent intraoperative ablation while 45% had another concomitant operation including cholecystectomy (28.8%), bowel resection (20.2%), or partial pancreatectomy (3.4%). Overall 30-d morbidity and mortality was 29% and 1.3%, respectively. On multivariate analysis, American Society of Anesthesiologists class ≥ 3 [odds ratios (OR), OR = 2.089, 95% confidence intervals (CI): 1.197-3.645], open approach (OR = 1.867, 95%CI: 1.148-3.036), right hepatectomy (OR = 1.618, 95%CI: 1.014-2.582), and prolonged operative time of > 230 min (OR = 1.731, 95%CI: 1.168-2.565) were associated with higher 30-d morbidity while intraoperative ablation and concomitant procedures were not.

LR for NELM was performed with relatively low postoperative morbidity and mortality. Concomitant procedures performed at the time of LR did not increase morbidity.

• Carcinoid
• Neuroendocrine tumor
• Primary tumor resection
• Intraoperative ablation
• Cholecystectomy
• Small bowel resection

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.

• Minimally invasive surgery
• Robotic hepatectomy
• Laparoscopic hepatectomy
• Hepatectomy resection
• Consensus statement

• Consensus
• Delphi Technique
• Gastroenterology/methods
• Gastroenterology/standards
• Hepatectomy/adverse effects
• Hepatectomy/methods
• Hepatectomy/standards
• Humans
• Laparoscopy/adverse effects
• Laparoscopy/methods
• Laparoscopy/standards
• Liver Diseases/surgery
• Randomized Controlled Trials as Topic
• Robotic Surgical Procedures/adverse effects
• Robotic Surgical Procedures/methods
• Robotic Surgical Procedures/standards
• Treatment Outcome

• adverse event
• mortality
• surgical criteria
• surgical treatment

• Adult
• Aged
• Aged, 80 and over
• Female
• Hepatectomy/methods
• Humans
• Male
• Middle Aged
• Robotic Surgical Procedures/methods
• Surgeons

• Laparoscopic liver resection (LLR)
• complication
• conversion
• predictive model

• Anterior approach
• Hepatocellular carcinoma
• Laparoscopic hepatectomy
• Liver neoplasm

• liver resection
• oncologic outcomes
• robot
• safety

Patients undergoing synchronous open splenectomy and hepatectomy (OSH) for concurrent hepatocellular carcinoma (HCC) and hypersplenism usually have major surgical trauma caused by the long abdominal incision. Surgical procedures that contribute to rapid recovery with the least possible impairment are desired by both surgeons and patients. The objective of this study was to explore outcomes in patients treated with simultaneous laparoscopic or open splenectomy and hepatectomy for hepatocellular carcinoma (HCC) with hypersplenism.

We retrospectively evaluated the treatment outcomes in 23 patients with cirrhosis, HCC, and hypersplenism, who underwent simultaneous laparoscopic splenectomy and hepatectomy (LSH; n = 12) or open splenectomy and hepatectomy (OSH; n = 11) from January 2012 through December 2015. Their perioperative variables were compared.

LSH was successful in all patients. There were nonsignificant similarities between the 2 groups in duration of operation, estimated blood loss, and volume of blood transfused (P > .05 each). Compared with OSH, LSH had a significantly shorter postoperative visual analog scale pain score (P < .001); shorter time to first oral intake (P < .001), passage of flatus (P < .05) and off-bed activity (P < .001); shorter postoperative duration of hospitalization (P < .001); fewer days of postoperative temperature >38.0°C (P < .01); fewer postoperative complications (P < .05); and better liver and renal function on postoperative days 7 (P < .05 each).

Simultaneous LSH is safe for selected patients with HCC and hypersplenism associated with liver cirrhosis.

• Hepatectomy
• Hepatocellular carcinoma
• Hypersplenism
• Laparoscopy
• Splenectomy

• Adult
• Aged
• Female
• Hepatectomy
• Humans
• Liver Neoplasms/complications
• Liver Neoplasms/pathology
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Minimally Invasive Surgical Procedures
• Obesity, Morbid/complications
• Retrospective Studies
• Treatment Outcome

• T32 DK070555 NIDDK NIH HHS

•

Utility of robotic system for heterogenous mix of hepatobiliary cases.

Robotic surgical system's ability to perform complex hepatobiliary surgeries is gaining momentum with outcomes similar to open surgery and advantages of minimal access surgery. The authors present their initial experience of a heterogenous spectrum of robotic hepatobiliary cases and the first reported case series from India.

Retrospective review of hepatobiliary cases done robotically from February 2015 to January 2016 was done.

The series has ten patients; with median age of 45 years (range 15–72). Etiologies were choledochal cyst type IVa, benign lower end common bile duct stricture (biliary reconstruction group); incidental gallbladder carcinoma, hepatocellular carcinoma, recurrent pyogenic cholangitis, polycystic liver disease, hemangioma, liver metastases, hydatid cyst (resection group). Median operative duration was 510 min; one patient needed intra-operative blood transfusion and there were no conversions to open surgery. One patient developed bile leak which was managed by biliary stenting and another thrombotic thrombocytopenic purpura during post-operative period. Median length of hospital stay was 6 days with average cost of robotic surgery being $1700 USD more for major hepatectomy and $900 USD more for biliary reconstruction compared to open procedure.

This initial series adds to existing data on the feasibility of robotic hepatobiliary cases with inherent advantages of minimal invasive surgery, however with limitation of availability and use of devices like cavitron ultrasonic surgical aspirator (CUSA) and higher operative cost.

• Biliary
• Laparoscopy
• Liver

• cost
• liver surgery
• robotic surgery

• da Vinci
• hepatic surgery
• liver resections
• minimally invasive surgery
• robotic

• MRI
• adenoma
• immunohistochemistry
• liver

• Abdominal drainage
• Bladder catheter
• Bowel preparation
• Nasogastric tube
• Re-feeding
• Resumption of diet

• Adult
• Aged
• Colorectal Neoplasms
• Female
• Hepatectomy/methods
• Hepatectomy/mortality
• Hepatectomy/statistics & numerical data
• Humans
• Kaplan-Meier Estimate
• Laparoscopy/methods
• Laparoscopy/mortality
• Laparoscopy/statistics & numerical data
• Length of Stay/statistics & numerical data
• Liver Neoplasms/mortality
• Liver Neoplasms/secondary
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Operative Time
• Propensity Score
• Prospective Studies
• Retrospective Studies
• Treatment Outcome

• 15956 Cancer Research UK

• Robotic liver resection
• minimally invasive surgery
• robotic hepatectomy

Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant (both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments (1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers’ practice. Continuous surgical training, as well as new technologies should augment the application of laparoscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.

• Minimally invasive surgery
• Laparoscopic surgery
• Hand-assisted laparoscopy
• Liver neoplasm
• Liver cirrhosis
• Living donor
• Liver
• Hepatectomy
• Liver transplantation

• Adult
• Aged
• Aged, 80 and over
• Female
• Follow-Up Studies
• Hepatectomy/methods
• Humans
• Laparoscopy/methods
• Liver Neoplasms/secondary
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Minimally Invasive Surgical Procedures/methods
• Neoplasm Metastasis
• Neoplasm Staging
• Retrospective Studies
• Treatment Outcome

• hepatocellular carcinoma
• intrahepatic cholangiocarcinoma
• liver cancer
• surgical margins

• computer tomography (CT)
• contrast-enhanced ultrasonography (CEUS)
• conventional ultrasonography (US)
• hepatic hemangioma (HH)
• ultrasonography contrast agent (UCA)

• Hemangioma/diagnosis
• Hemangioma/etiology
• Hemangioma/pathology
• Hemangioma/therapy
• Humans
• Liver Neoplasms/diagnosis
• Liver Neoplasms/etiology
• Liver Neoplasms/pathology
• Liver Neoplasms/therapy