Robotic Left Hepatectomy with En Bloc Biliary Resection and Roux-en-Y Hepaticojejunostomy: A Technique of Portal Venous Tangential Vascular Reconstruction.

BACKGROUND: Robotic technology is increasingly utilized in perihilar cholangiocarcinoma treatments, requiring expertise in minimally invasive liver surgeries and biliary reconstructions. These resections often involve vascular and multiple sectoral bile duct reconstructions. Minimally invasive vascular repairs are now emerging with promising outcomes, potentially altering criteria for selecting minimally invasive hepatobiliary tumor resections. In this multimedia article, we describe our technique of robotic portal venous tangential primary reconstruction with right sectoral bile duct unification ductoplasty for the treatment of perihilar cholangiocarcinoma using the robotic approach. METHODS: The robotic technique was chosen in this operation with preoperative anticipation of needing vascular resection and reconstruction due to left portal vein tumor involvement. Additionally, a Roux-en-Y hepaticojejunostomy to the right anterior and posterior sectoral duct was planned for biliary reconstruction. Proximal and distal vascular control of the portal vein bifurcation was obtained by placing vascular bulldog clamps across the main and right portal veins. Once an R0 vascular margin was obtained on the left portal vein, portal bifurcation was tangentially repaired. Perfusion to the liver was then restored, and left hemihepatectomy with en bloc extrahepatic biliary resection was carried out, followed by Roux-en-Y hepaticojejunostomy reconstruction to the right anterior and posterior sectoral bile ducts, as a single anastomosis. RESULTS: The operation was uneventful without vascular or biliary complications. Robotic unification ductoplasty circumvented the need for multiple anastomoses. CONCLUSION: The robotic approach for left-sided perihilar cholangiocarcinoma resections, requiring precise biliovascular management, is safe, feasible, and efficient. This method demonstrates the potential of robotic techniques as an alternative to traditional open surgery.

Robotic Biliary Stricturoplasty and Roux-en-Y Hepaticojejunostomy After Hepatic Artery Infusion Pump Injury.

BACKGROUND: Hepatic artery infusion pump (HAIP) with floxuridine/dexamethasone and systemic chemotherapy is an established treatment regimen, which had been reported about converting 47% of patients with stage 4 colorectal liver metastasis from unresectable to resectable.1,2 To this effect, HAIP chemotherapy contributes to prolonged survival of many patients, which otherwise may not have other treatment options. Biliary sclerosis, however, is a known complication of the HAIP treatment, which occurs in approximately 5.5% of patients receiving this modality as an adjuvant therapy after hepatectomy and in 2% of patients receiving HAIP treatment for unresectable disease.3 While biliary sclerosis diffusely affects the perihilar and intrahepatic biliary tree, a dominant stricture maybe found in select cases, which gives an opportunity for a local surgical treatment after failure of endoscopic stenting/dilations. While the use of minimally invasive approach to biliary surgery is gradually increasing,4 there have been no descriptions of its application in this scenario. In this video, we demonstrate the use of minimally invasive robotic technique for biliary stricturoplasty and Roux-en-Y (RY) hepaticojejunostomy to treat persistent right hepatic duct stricture after HAIP chemotherapy. PATIENT: A 68-year-old woman with history of multifocal bilobar stage 4 colorectal liver metastasis presented to our office with obstructive jaundice and recurrent cholangitis that required nine endoscopic retrograde cholangiopancreatographies (ERCPs) and a placement of internal-external percutaneous transhepatic biliary drain (PTBD) by interventional radiology within the past 2 years. Her past surgical history was consistent with laparoscopic right hemicolectomy 3 years prior, followed by a left lateral sectorectomy with placement of an HAIP for adjuvant treatment. The patient had more than ten metastatic liver lesions within the right and left lobe, ranging from 2 to 3 cm in size at the time of HAIP placement. The patient had a histologically normal background liver parenchyma before the HAIP chemotherapy treatment. The patient did not have any history of alcohol use, diabetes mellitus, metabolic syndrome, nonalcoholic steatohepatitis, or other underlying intrinsic liver disorders, which are known to contribute to the development of hepatic fibrosis. Despite a radiologically disease-free status, the patient started to have episodes of acute cholangitis 1 year after the placement of HAIP that required multiple admissions to a local hospital. The HAIP was subsequently removed once the diagnosis of biliary sclerosis was made despite dose reductions and treatment with intrahepatic dexamethasone for almost 1 year. In addition to this finding, the known liver metastases have shown complete radiological resolution. Therefore further treatment with HAIP was deemed unnecessary, and pump removal was undertaken. Magnetic resonance imaging showed a dominant stricture at the junction of the right anterior and right posterior sectoral hepatic duct. The location of the dominant stricture was confirmed by an ERCP and cholangioscopy. Absence of neoplasia was confirmed with multiple cholangioscopic biopsies. Multiple endoscopic and percutaneous attempts with stent placement failed to dilate the area of stricture. Postprocedural cholangiographies showed a persistent significant narrowing, which led to multiple recurrent obstructive jaundice and severe cholangitis. While the use of surgical approach is rarely needed in the treatment of biliary sclerosis, a decision was made after extensive multidisciplinary discussions to perform a robotic stricturoplasty and RY hepaticojejunostomy with preservation of the native common bile duct. TECHNIQUE: The operation began with a laparoscopic adhesiolysis to allow for identification of HAIP tubing (which was later removed) and placement of robotic ports. A peripheral liver biopsy was obtained to evaluate the degree of hepatic parenchymal fibrosis. Porta hepatic area was carefully exposed without causing an inadvertent injury to the surrounding hollow organs. Biopsy of perihepatic soft tissues was taken as appropriate to rule out any extrahepatic disease. The common bile duct and common hepatic duct with ERCP stents within it were identified with the use of ultrasonography. Anterior wall of the common hepatic duct was then opened, exposing the two plastic stents. Cephalad extension of the choledochotomy was made toward the biliary bifurcation and the right hepatic duct. The distal common bile duct was preserved for future endoscopic access to the biliary tree. After lowering the right-sided hilar plate, dense fibrosis around the right hepatic duct was divided sharply with robotic scissors, achieving a mechanical release of the dominant stricture. An intraoperative cholangioscopy was performed to confirm adequate openings of the right hepatic duct secondary and tertiary radicles, as well as patency of the left hepatic duct. A 4-Fr Fogarty catheter was used to sweep the potential biliary debris from within the right and left hepatic lobe. Finally, a confirmatory choledochoscopy was performed to ensure patency and clearance of the right-sided intrahepatic biliary ducts and the left hepatic duct before fashioning the hepaticojejunostomy. A 40-cm antecolic roux limb was next prepared for the RY hepaticojejunostomy. A side-to-side double staple technique was utilized to create the jejunojejunostomy. The common enterotomy was closed in a running watertight fashion. Once the roux limb was transposed to the porta hepatic in a tension-free manner, a side-to-side hepaticojejunostomy was constructed in a running fashion by using absorbable barbed sutures. The index suture was placed at 9 o'clock location, and the posterior wall of the anastomosis was run toward 3 o'clock location. This stabilized the roux limb to the bile duct. The anterior wall of the anastomosis was next fashioned by using a running technique from both corners of the anastomosis toward the middle (12 o'clock), where both sutures were tied together. This completed a wide side-to-side hepaticojejunostomy anastomosis encompassing the upper common hepatic duct, biliary bifurcation, and the right hepatic duct. A closed suction drain was placed before closing.5 RESULTS: The operative time was approximately 4 hr with 60 ml of blood loss. The postoperative course was uneventful. The patient was discharged home on postoperative Day 5 after removal of the closed suction drain, confirming the absence of bile leak. The patient had developed periportal/periductal fibrosis, cholestasis, and moderate-severe parenchymal fibrosis (F3-F4) based on liver biopsy, often seen in patients treated with a long course of floxuridine HAIP chemotherapy. The patient is clinically doing well at 1 year outpatient follow-up without any evidence of recurrent cholangitis at the time of this manuscript preparation. CONCLUSIONS: Robotic biliary stricturoplasty with RY hepaticojejunostomy for treatment of biliary sclerosis after HAIP chemotherapy is safe and feasible. Appropriate experience in minimally invasive hepatobiliary surgery is necessary to achieve this goal.

Initial clinical outcomes of robotic resection for perihilar cholangiocarcinoma: Is it safe and effective?

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.

A decade of experience with minimally invasive anti-reflux operations: robot vs. LESS.

BACKGROUND: The increasing use of robotic systems for anti-reflux operations prompted this study to evaluate and compare the efficacy of robotic and Laparo-Endoscopic Single-Site (LESS) approaches. METHODS: From 2012, 228 robotic fundoplication and 518 LESS fundoplication patients were prospectively followed, analyzing perioperative metrics. Data are presented as median (mean ± SD); significance at p ≤ 0.05. RESULTS: Patients undergoing a robotic vs. LESS fundoplication were 67 (64 ± 13.7) vs. 61 (59 ± 15.1) years-old with BMIs of 25 (25 ± 3.2) vs. 26 (25 ± 3.9) kg/m2 (p = 0.001 and 1.00, respectively). 72% of patients who underwent the robotic approach had a previous abdominal operation(s) vs 44% who underwent the LESS approach (p = 0.0001). 38% vs. 8% had a re-operative fundoplication (p = 0.0001), 59% vs. 45% had a type IV hiatal hernia (p = 0.0004). Operative duration was 160 (176 ± 76.7) vs. 130 (135 ± 50.5) min (p = 0.0001). There were 0 (robotic) vs. 5 (LESS) conversions to a different approach (p = 0.33). 5 Patients vs. 3 patients experienced postoperative complications (p = 0.06), and length of stay (LOS) was 1 (2 ± 2.6) vs. 1 (1 ± 3.2) days (p = 0.0001). Patient symptomatic dysphagia preoperatively for the robotic vs. LESS approach was scored as 2 (2.4 ± 1.9) vs. 1 (1.9 ± 1.6). Postoperatively, symptomatic dysphagia was scored as 1 (1.5 ± 1.6) vs. 1 (1.7 ± 1.7). The change in these scores was - 1 (- 1 ± 2.2) vs. 0 (- 0.5 ± 2.2) (p = 0.004). CONCLUSION: Despite longer operative times and LOS in older patients, the robotic approach is efficient in undertaking very difficult operations, including patients with type IV or recurrent hiatal hernias. Furthermore, preoperative anti-reflux operations were more likely to be undertaken with the robotic approach than the LESS approach. The patient's postoperative symptomatic dysphagia improved relatively more than after the LESS approach. The vast majority of patients who underwent the LESS approach enjoyed improved cosmesis, thus, making LESS a stronger candidate for more routine operations. Despite patient selection bias, the robotic and LESS approaches to anti-reflux operations are safe, efficacious, and should be situationally utilized.

The robotic-assisted laparoscopic approach to biliary tract resection and reconstruction for benign indications: A single-center experience.

BACKGROUND: Benign biliary disease (BBD) is a prevalent condition involving patients who require extrahepatic bile duct resections and reconstructions due to nonmalignant causes. METHODS: This study followed all patients who underwent biliary resections for BBD between 2015 and 2023. We excluded those with malignant conditions and patients who had an 'open' operation. Based on the patient's anatomy, the procedures employed were either robotic Roux-en-Y hepaticojejunostomy (RYHJ) or robotic choledochoduodenostomy (CDD). RESULTS: From the 33 patients studied, 23 were female, and 10 were male. Anesthesiology (ASA) class was 3 ± 0.5; the MELD score was 9 ± 4.1; the Child-Pugh score was 6 ± 1.7. The primary indications for undergoing the operation included iatrogenic bile duct injuries, biliary strictures, and type 1 choledochal cysts. The average surgical duration was about 272 min, and the average blood loss amounted to 79 mL. Postoperatively, three patients experienced major complications, all attributed to anastomotic leaks. The average hospital stay was 4 days, with a readmission rate of 15% within 30 days. During an average follow-up period of 33 months, one patient had to undergo a revision at 18 months due to stricture. This necessitated further duct resection and reanastomosis. Notably, there were no reported hepatectomies, no conversion to the 'open' method, no intraoperative complications, and no mortalities. CONCLUSIONS: Robotic extrahepatic bile duct resection and reconstruction with Roux-en-Y hepaticojejunostomy or choledochoduodenostomy is safe with an acceptable postoperative morbidity, short hospital length of stay, and low postoperative stricture rate at intermediate duration follow-up.

Diagnosis to dissection: AI's role in early detection and surgical intervention for gastric cancer.

Gastric cancer remains a formidable health challenge worldwide; early detection and effective surgical intervention are critical for improving patient outcomes. This comprehensive review explores the evolving landscape of gastric cancer management, emphasizing the significant contributions of artificial intelligence (AI) in revolutionizing both diagnostic and therapeutic approaches. Despite advancements in the medical field, the subtle nature of early gastric cancer symptoms often leads to late-stage diagnoses, where survival rates are notably decreased. Historically, the treatment of gastric cancer has transitioned from palliative care to surgical resection, evolving further with the introduction of minimally invasive surgical (MIS) techniques. In the current era, AI has emerged as a transformative force, enhancing the precision of early gastric cancer detection through sophisticated image analysis, and supporting surgical decision-making with predictive modeling and real-time preop-, intraop-, and postoperative guidance. However, the deployment of AI in healthcare raises significant ethical, legal, and practical challenges, including the necessity for ongoing professional education and the development of standardized protocols to ensure patient safety and the effective use of AI technologies. Future directions point toward a synergistic integration of AI with clinical best practices, promising a new era of personalized, efficient, and safer gastric cancer management.

A comparative analysis of robotic versus open pancreaticoduodenectomy in octogenarians.

Old age is a predictor of increased morbidity following pancreatic operations. This study was undertaken to compare the peri-operative variables between robotic and 'open' pancreaticoduodenectomy, in octogenarians (≥ 80 years of age). Since 2012, with IRB approval, we retrospectively followed 69 patients, who underwent robotic (n = 42) and 'open' (n = 27) pancreaticoduodenectomy. Statistical analysis was performed using chi-square test and Student's t test. Data are presented as median(mean ± SD), and significance accepted with 95% probability. Patients who underwent the robotic approach had a greater Charlson Comorbidity Index [6 (6 ± 1.6) vs 5 (5 ± 1.0), (p = 0.01)] and previous abdominal operations [n = 24 (57%) vs n = 9 (33%), (p = 0.04)]. The robotic approach led to longer operative time [426 (434 ± 95.8) vs 240 (254 ± 71.1) minutes, (p < 0.0001)], decreased blood loss [200 (291 ± 289.2) vs 426 (434 ± 95.8) mL (p = 0.008)], and decreased intraoperative blood transfusions (p < 0.05). Patients who underwent robotic pancreaticoduodenectomy had comparable and at times superior outcomes, consistent with the literature regarding robotic and 'open' pancreaticoduodenectomy. This study indicates that robotic pancreaticoduodenectomy continues to offer same benefits for patients of advanced age and demonstrates age should not be a preclusion to robotic operations.

Robotic Biliary Resection for Type I Choledochal Cyst With Dual Hepaticojejunostomy.

The distal bile duct was isolated and transected with a frozen section examination confirming the absence of malignancy. Attention was then shifted to constructing a 60 cm Roux limb by first identifying and transecting the proximal jejunum 40 cm from the ligamentum of Treitz. A side-to-side stapled jejunojejunostomy anastomosis was completed. The Roux limb was transposed toward the porta hepatis through an antecolic approach.

A single institution's experience with robotic resections of biliary tract cancers: an analysis of the short-term outcomes and long-term survival.

INTRODUCTION: Perihilar cholangiocarcinoma, intrahepatic cholangiocarcinoma (IHCC), and gall bladder cancer are difficult malignancies to treat and are characterized by a tendency for local recurrence and a generally unfavorable prognosis. Surgical resection offers the only potential cure, conventionally performed via the open approach. Although minimally invasive approaches show promise, data remain limited. METHODS: With the institutional review board's approval, we prospectively followed 100 patients between 2013 and 2023 who underwent robotic surgical resection for perihilar, IHCC, and gallbladder cholangiocarcinoma. Data are presented as median (mean ± SD). Significance was accepted at P ≤ .05. RESULTS: The median patient age was 70 years, and the median operative duration was 333 min, with an estimated blood loss of 200 mL. Importantly, no unplanned conversions occurred, and only 1 intraoperative complication occurred within the IHCC cohort. The median length of stay was 4 days. There were a total of 19 postoperative complications and 19 readmissions within 30 days. Additionally, there were 3 in-hospital mortalities and 5 90-day mortalities. R0 resection was achieved in 87% of patients and R1 resection in 13%. At a median follow-up of 36 months, 62% of patients demonstrated disease-free survival, whereas 6% continued to live with the disease, and 32% did not survive. CONCLUSION: Our experience demonstrates the feasibility and safety of robotic resection for these complex malignancies, yielding promising short-term outcomes. Further investigation is required to ascertain the long-term oncologic outcomes.

A decade of experience with 530 minimally invasive robotic hepatectomies from a single tertiary hepatobiliary center: analysis of short-term outcomes and oncologic survival.

BACKGROUND: This research is the first study in the United States to document more than a decade of experience with 530 patients who underwent robotic hepatectomy at a single high-volume institution. METHODS: With institutional review board approval, a prospectively collected database of consecutive patients who underwent robotic hepatectomy from 2012 to January 2024 was reviewed. Data are presented as median (mean ± SD). RESULTS: Of the 530 robotic hepatectomies, 231 (44.0%) were minor resections, 133 (25.0%) were technically major resections, and 166 (31.0%) were major resections. The patients were aged 63.0 (61.0 ± 14.7) years with a body mass index of 28.0 (29.0 ± 7.9) kg/m2. Cirrhosis was present in 80 patients (19.0%), with an American Society of Anesthesiologists score of 3.0 (3.0 ± 0.5) and a Model for End-Stage Liver Disease score of 7.0 (8.0 ± 3.0). Of note, 280 patients (53.0%) had previous abdominal operations, and 44 patients (8%) had previous liver resections. The operative time was 233.0 (260.0 ± 130.7) minutes, and the estimated blood loss was 100.0 (165.0 ± 205.0) mL. Moreover, 353 patients (66%) had hepatectomies for neoplastic disease, and 500 patients (95%) had an R0 resection margin. The tumor size was 4.0 (5.0 ± 3.6) cm. The total 90-day postoperative complications were 45 (8%), of which 21 (4%) were classified as major complications (Clavien-Dindo score of >III). The length of stay was 3.0 (4.0 ± 3.7) days, and the 30-day readmission rate was 86 (16%). The overall survival rates at 1, 3, and 5 years were 82%, 65%, and 59% for colorectal liver metastases, 84%, 68%, and 60% for hepatocellular carcinoma, and 79%, 61%, and 50% for intrahepatic cholangiocarcinoma, respectively. CONCLUSION: After a decade of application and optimization at a high-volume institution, the robotic approach has been demonstrated to be a safe and effective approach to liver resection.

The Oncological Stress Test of Neoadjuvant Therapy: A Systematic Review in Outcomes of Neoadjuvant Therapy Compared to Upfront Resection Approach for Borderline Resectable Pancreatic Adenocarcinoma.

Pancreatic adenocarcinoma, increasingly diagnosed in the United States, has a disheartening initial resection rate of 15%. Neoadjuvant therapy, particularly FOLFIRINOX and gemcitabine-based regimens, is gaining favor for its potential to improve resectability rates and achieving microscopically negative margins (R0) in borderline resectable cases, marked by intricate arterial or venous involvement. Despite surgery being the sole curative approach, actual benefit of neoadjuvant therapy remains debatable. This study scrutinizes current literature on oncological outcomes post-resection of borderline resectable pancreatic cancer. A MEDLINE/PubMed search was conducted to systematically compare oncological outcomes of patients treated with either neoadjuvant therapy with intent of curative resection or an "upfront resection" approach. A total of 1293 studies were initially screened and 30 were included (n = 1714) in this analysis. All studies included data on outcomes of patients with borderline resectable pancreatic adenocarcinoma being treated with neoadjuvant therapy (n = 1387) or a resection-first approach (n = 356). Patients treated with neoadjuvant therapy underwent resection 52% of the time, achieving negative margins of 43% (n = 601). Approximately 77% of patients who received an upfront resection underwent a successful resection, with 39% achieving negative margins. Neoadjuvant therapy remains marginally efficacious in treatment of borderline resectable pancreatic adenocarcinoma, as patients undergo an operation and successful resection less often when treated with neoadjuvant therapy. Rates of curative resection are comparable, despite neoadjuvant therapy being a primary recommendation in borderline resectable cases and employed more often than upfront resection. Upfront resection may offer improved resection rates by intention-to-treat, which can provide more patients with paths to curative resection.

Weighing the outcomes: the role of BMI in complex robotic esophageal and hepatobiliary operations.

BACKGROUND: The correlation between body mass index (BMI) and surgical outcomes has emerged as a critical consideration in complex abdominal operations. While elevated BMI is often associated with increased perioperative risk, its specific effects on the outcomes of robotic surgeries remain inadequately explored. This study assesses the impact of BMI on perioperative variables of complex esophageal and hepatopancreaticobiliary (HPB) robotic operations. METHODS: Following IRB approval, we prospectively followed 607 patients undergoing pancreaticoduodenectomy, trans-hiatal esophagectomy (THE), major liver resection or distal pancreatectomy with splenectomy, all performed robotically. Perioperative data retrieved included operative duration, estimated blood loss (EBL), intraoperative and postoperative complications, conversions to an 'open' operation and length of stay (LOS). Z scores were assigned to each variable to standardize operations, and the variables were then regressed against BMI. For illustrative purposes, data are presented as median(mean ± standard deviation). RESULTS: Between 2012 and 2020, surgeries included 71 THE, 122 distal pancreatectomies with splenectomies, 129 major hepatectomies and 285 pancreaticoduodenectomies. Median age was 67(65 ± 12.5) years old, and BMI was 27(28 ± 5.5) kg/m2. Operative duration for all operations was 349(355 ± 124.5) min and had a positive correlation with increasing BMI (p = 0.004), specifically for robotic THE and robotic pancreaticoduodenectomy, with both operative durations having positive correlation with increasing BMI (p = 0.02 and p = 0.05). No significant correlation with BMI was found for EBL, intraoperative or postoperative complications, conversion to 'open' surgery, or LOS. CONCLUSION: Elevated BMI is associated with longer operative durations in select robotic surgeries, such as trans-hiatal esophagectomy and pancreaticoduodenectomy, and highlights the need for strategic planning in these patients.

Comparison of IWATE, Institut Mutualiste Montsouris, and Southampton Laparoscopic Liver Resection Difficulty Scoring Systems for Predicting Intra and Postoperative Outcomes in Robotic Hepatectomy.

BACKGROUND: IWATE, Institut Mutualiste Montsouris (IMM), and Southampton are established difficulty scoring systems (DSS) for laparoscopic hepatectomy, yet none specifically address robotic hepatectomy. Our study evaluates these 3 DSS for predicting perioperative outcomes in robotic hepatectomy. METHODS: With IRB approval, we prospectively followed 359 consecutive patients undergoing robotic hepatectomies, assessing categorical metrics like conversions to open, intra/postoperative issues, Clavien-Dindo Score (≥III), 30 and 90-day mortality, and 30-day readmissions using Receiver Operating Characteristic (ROC) curves and Area Under the Curve (AUC) to determine efficacy in predicting their occurrence for each DSS. Continuous metrics such as operative duration, estimated blood loss (EBL), length of stay, and total cost were analyzed using Spearman's correlation and regression. Predictive strength was significant with an AUC or correlation ≥.700 and P-value ≤.05. RESULTS: IMM had highest predictive accuracy for conversions to open (AUC = .705) and postoperative complications (AUC = .481). Southampton was most accurate in predicting Clavien Dindo ≥ III complications (AUC = .506). IWATE excelled in predicting 30-day mortality (AUC = .552), intraoperative issues (AUC = .798), In-hospital mortality (AUC = .450), 90-day mortality (AUC = .596), and readmissions (AUC = .572). Regression showed significant relationships between operative duration, EBL, and hospital cost with increasing scores for all DSS (P ≤ .05). DISCUSSION: Statistical analysis of the 3 DSS indicates that each has specific strengths that can best predict intra- and/or postoperative outcomes. However, all showed inaccuracies and conflicting relationships with the variables, indicating lack of substantial hierarchy between DSS. Given these inconsistencies, a dedicated comprehensive DSS should be created for robotic hepatectomy.

Deconstructing the Operative Times of Robotic Pancreaticoduodenectomy.

INTRODUCTION: Despite numerous benefits offered, robotic procedures take longer than "open" procedures. With the intent to reduce operative duration, we examined the degree each operative step contributes to operative duration in robotic pancreaticoduodenectomy. MATERIALS AND METHODS: With IRB approval, we prospectively followed 88 patients to determine the duration of robotic pancreaticoduodenectomy, and the duration of 12 key steps. Each operative step was regressed against the operation date, from most distant to most recent operation date. Data are presented as median (mean ± SD) for illustrative purposes. RESULTS: Patients were 73 (71 ± 10.2) years old; 53% were men. Total time patient spent in the operating room was 471 (488 ± 93.3) minutes. Total operative time was 399 (421 ± 90.7) minutes. Total console time was 293 (297 ± 68.0) minutes. The 3 longest portions of the operation were (1) mobilization of the specimen and specimen extraction; (2) construction of the duodenojejunostomy; and (3) closure. CONCLUSION: A third of the operative time is spent off the console. Over half of the steps required more than 20 minutes each to complete. Since robotic operations are associated with shorter LOS and without increased complication rates relative to "open" operations, salutary benefit can be gained by decreasing operative times of robotic procedures. Operative duration is an important metric that needs to be addressed. We need to target the most time-consuming steps, and break them into smaller pieces, to reach optimal efficiency and provide the benefits of decreased operative duration to the patients, hospitals, and providers.

Effect of IWATE laparoscopic difficulty score on postoperative outcomes and costs for robotic hepatectomy: Are complex resections more expensive?

BACKGROUND: The IWATE criteria, a four-level classification system for laparoscopic hepatectomy, measures technical complexity but lacks studies on its impact on outcomes and costs, especially in robotic surgeries. This study evaluated the effects of technical complexity on perioperative outcomes and costs in robotic hepatectomy. METHODS: Since 2013, we prospectively followed 500 patients who underwent robotic hepatectomy. Patients were classified into four levels of IWATE scores; (low [0-3], intermediate [4-6], advanced [7-9], and expert [10-12]) determined by tumor characteristics, liver function and resection extent. Perioperative variables were analyzed with significance accepted at a p-value ≤.05. RESULTS: Among 500 patients, 337 (67%) underwent advanced to expert-level operations. Median operative duration was 213 min (range: 16-817 min; mean ± SD: 240 ± 116.1 min; p < .001) and estimated blood loss (EBL) was 95 mL (range: 0-3500 mL; mean ± SD:142 ± 171.1 mL; p < .001). Both operative duration and EBL showed positive correlations with increasing IWATE scores. Median length of stay (LOS) of 3 days (range: 0-34; mean ± SD:4 ± 3.0 days; p < .001) significantly correlated with IWATE score. Total cost of $25 388 (range: $84-354 407; mean ± SD: 29752 ± 20106.8; p < .001) also significantly correlated with operative complexity, however hospital reimbursement did not. No correlation was found between IWATE score and postoperative complications or mortality. CONCLUSIONS: Clinical variables such as operative duration, EBL, and LOS correlate with IWATE difficulty scores in robotic hepatectomy. Financial metrics such as costs but not reimbursement received by the hospital correlate with IWATE scores.

Hospital readmissions after robotic hepatectomy for neoplastic disease: Analysis of risk factors, survival, and economical impact. A logistical regression and propensity score matched study.

BACKGROUND: As the first comprehensive investigation into hospital readmissions following robotic hepatectomy for neoplastic disease, this study aims to fill a critical knowledge gap by evaluating risk factors associated with readmission and their impact on survival and the financial burden. METHODS: The study analyzed a database of robotic hepatectomy patients, comparing readmitted and non-readmitted individuals post-operatively using 1:1 propensity score matching. Statistical methods included Chi-square, Mann-Whitney U, T-test, binomial logistic regression, and Kaplan-Meier analysis. RESULTS: Among 244 patients, 44 were readmitted within 90 days. Risk factors included hypertension (p â€‹= â€‹0.01), increased Child-Pugh score (p â€‹< â€‹0.01), and R1 margin status (p â€‹= â€‹0.05). Neoadjuvant chemotherapy correlated with lower readmission risk (p â€‹= â€‹0.045). Readmissions didn't significantly impact five-year survival (p â€‹= â€‹0.42) but increased fixed indirect hospital costs (p â€‹< â€‹0.01). CONCLUSIONS: Readmission post-robotic hepatectomy correlates with hypertension, higher Child-Pugh scores, and R1 margins. The use of neoadjuvant chemotherapy was associated with a lower admission rate due to less diffuse liver disease in these patients. While not affecting survival, readmissions elevate healthcare costs.

Learning curve analysis after 500 robotic hepatectomies.

BACKGROUND: The robotic platform is growing in popularity for hepatobiliary resections. Although the learning curve for basic competency has been reported, this is the first study to analyze the learning curve to achieve long-term mastery on a decade of experience with more than 500 robotic hepatectomies. METHODS: After institutional review board approval, 500 consecutive robotic hepatectomies from 2013 to 2023 were analyzed. Cumulative sum (CUSUM) analysis using operative duration was used to determine the learning curves. RESULTS: A total of 500 patients were included in this study: composed of 230 men (46.0 %) and 270 women (54.0 %), aged 63.0 (61.0 ± 14.6) years, with a body mass index of 28.0 (29.0 ± 8.0) kg/m2, a Model for End-Stage Liver Disease score of 7 (8 ± 3.0), an albumin-bilirubin score of -3.0 (-3.0 ± 0.6), and a Child-Pugh score of 5.0 (5.0 ± 0.7). Operative duration was 235.0 (260.1 ± 131.9) minutes, estimated blood loss was 100.0 (165.0 ± 208.1) mL, tumor size was 4.0 (5.0 ± 3.5) cm, and 94.0 % of patients achieved R0 margins. The length of hospital stay was 3.0 (4.0 ± 3.7) days, with 4.0 % of patient having major complications. Of note, 30-day readmission was 17.0 %, 30-day mortality was 2.0 %, and 90-day mortality was 3.0 %. On CUSUM analysis, the learning curve for minor resection (n = 215) was 75 cases, major resection (n = 154) was 100 cases, and technically challenging minor resection (n = 131) was 57 cases. Gaining more experience in performing surgical procedures resulted in shorter operative duration, lower blood loss, higher R0 resections, and lower major postoperative complications. CONCLUSION: The minimum number of robotic hepatectomies to overcome the learning curves for mastery of minor, major, and technically challenging minor resections was significant. Our study can help guide surgeons in their early experience to optimize patient safety and outcomes.