HEPATOBILIARY SURGERY

Robotic Hepatic Resection

In addition to treating critical injuries, major hepatic resection is performed to remove benign neoplasms (adenoma, focal nodular hyperplasia, hemangioma), cysts (echinococcal), and malignant neoplasms (hepatoma, cholangiocarcinoma, metastases).

In children and adults if the remaining hepatic tissue is normal, as much as 70% of the liver can be removed. Screening of high-risk individuals allows for earlier detection of hepatocellular carcinoma or hepatic metastases from other cancer (mainly colorectal cancer). In the former group, cirrhotic, hepatitis B carriers, and family members of patients with hepatocellular carcinoma should undergo yearly measurements of alpha-fetoprotein (AFP) and hepatic ultrasonography.

In the latter group, measurements of carcinoembryonic antigen (CEA) and hepatic ultrasonography are indicated every 6 months in the first 3 years, then yearly for at least 2 years more, after resection of a colorectal cancer.

In standard open surgery, under general anesthesia with the patient placed in the supine position, major hepatic resection is performed with a right sub costal incision extended with a left sub costal and often with a vertical midline one up to the xyphoid process. Data reported in the scientific literature show an average blood loss of 600 ml. with 49% of patients transfused at any time, an operative time of about 4 hours, and expected postoperative hospital stay of 7 to 12 days.

The explosive growth in the popularity and the widespread acceptance of laparoscopic surgery has encouraged surgeons to apply laparoscopic approach to the management of a number of hepatic tumors. Unfortunately, application of laparoscopy to major hepatectomy has been slowed by the technical difficulties related to maintaining hemostasis at the transection plane, controlling hemorrhage from intra hepatic vessels, and dealing with deeper vascular structures.

Minimally invasive approach to hepatic resections remains a prerogative of few high-specialization surgical units. Technical difficulties and fear of major complications are the main limiting factors. A small number of experiences are reported in the literature: in most instances fully laparoscopic techniques are limited to small or medium hepatectomies (wedge resections, segmentectomies, left lateral segmentectomies).

The most frequent approach to major resections is hand-assisted, to overcome pitfalls and drawbacks of standard laparoscopy: limited movements, inability to perform high-precision sutures, unnatural positions for the surgeon, and flat vision. The application of robotic technology allows overcoming these limitations favoring a full minimally invasive approach to major hepatic resections, and expanding the advantages of minimally invasive surgery to an increasing number of patients.

The benefits associated with robotic technology include less blood loss, faster recovery, less scarring, and reduced postoperative pain, so that the expected postoperative hospital stay is about 3 days; less then 3% of patients are transfused with an operative time of about 4 hours.