Implementation and Outcome of Robotic Liver Surgery in the Netherlands: A Nationwide Analysis.

OBJECTIVE: To determine the nationwide implementation and surgical outcome of minor and major robotic liver surgery (RLS) and assess the first phase of implementation of RLS during the learning curve. BACKGROUND: RLS may be a valuable alternative to laparoscopic liver surgery. Nationwide population-based studies with data on implementation and outcome of RLS are lacking. METHODS: Multicenter retrospective cohort study including consecutive patients who underwent RLS for all indications in 9 Dutch centers (August 2014-March 2021). Data on all liver resections were obtained from the mandatory nationwide Dutch Hepato Biliary Audit (DHBA) including data from all 27 centers for liver surgery in the Netherlands. Outcomes were stratified for minor, technically major, and anatomically major RLS. Learning curve effect was assessed using cumulative sum analysis for blood loss. RESULTS: Of 9437 liver resections, 400 were RLS (4.2%) procedures including 207 minor (52.2%), 141 technically major (35.3%), and 52 anatomically major (13%). The nationwide use of RLS increased from 0.2% in 2014 to 11.9% in 2020. The proportion of RLS among all minimally invasive liver resections increased from 2% to 28%. Median blood loss was 150 mL (interquartile range 50-350 mL] and the conversion rate 6.3% (n=25). The rate of Clavien-Dindo grade ≥III complications was 7.0% (n=27), median length of hospital stay 4 days (interquartile range 2-5) and 30-day/in-hospital mortality 0.8% (n=3). The R0 resection rate was 83.2% (n=263). Cumulative sum analysis for blood loss found a learning curve of at least 33 major RLS procedures. CONCLUSIONS: The nationwide use of RLS in the Netherlands has increased rapidly with currently one-tenth of all liver resections and one-fourth of all minimally invasive liver resections being performed robotically. Although surgical outcomes of RLS in selected patient seem favorable, future prospective studies should determine its added value.

Outcomes of a Multicenter Training Program in Robotic Pancreatoduodenectomy (LAELAPS-3).

OBJECTIVE: To assess feasibility and safety of a multicenter training program in robotic pancreatoduodenectomy (RPD) adhering to the IDEAL framework for implementation of surgical innovation. BACKGROUND: Good results for RPD have been reported from single center studies. However, data on feasibility and safety of implementation through a multicenter training program in RPD are lacking. METHODS: A multicenter training program in RPD was designed together with the University of Pittsburgh Medical Center, including an online video bank, robot simulation exercises, biotissue drills, and on-site proctoring. Benchmark patients were based on the criteria of Clavien. Outcomes were collected prospectively (March 2016-October 2019). Cumulative sum analysis of operative time was performed to distinguish the first and second phase of the learning curve. Outcomes were compared between both phases of the learning curve. Trends in nationwide use of robotic and laparoscopic PD were assessed in the Dutch Pancreatic Cancer Audit. RESULTS: Overall, 275 RPD procedures were performed in seven centers by 15 trained surgeons. The recent benchmark criteria for low-risk PD were met by 125 (45.5%) patients. The conversion rate was 6.5% (n = 18) and median blood loss 250ml [interquartile range (IQR) 150-500]. The rate of Clavien-Dindo grade ≥III complications was 44.4% (n = 122), postoperative pancreatic fistula (grade B/C) rate 23.6% (n = 65), 90-day complication-related mortality 2.5% (n = 7) and 90-day cancer-related mortality 2.2.% (n = 6). Median postoperative hospital stay was 12 days (IQR 8-20). In the subgroup of patients with pancreatic cancer (n = 80), the major complication rate was 31.3% and POPF rate was 10%. Cumulative sum analysis for operative time found a learning curve inflection point at 22 RPDs (IQR 10-35) with similar rates of Clavien-Dindo grade ≥III complications in the first and second phase (43.4% vs 43.8%, P = 0.956, respectively). During the study period the nationwide use of laparoscopic PD reduced from 15% to 1%, whereas the use of RPD increased from 0% to 25%. CONCLUSIONS: This multicenter RPD training program in centers with sufficient surgical volume was found to be feasible without a negative impact of the learning curve on clinical outcomes.

Pan-European survey on the implementation of robotic and laparoscopic minimally invasive liver surgery.

BACKGROUND: Laparoscopic and robotic minimally invasive liver surgery (MILS) is gaining popularity. Recent data and views on the implementation of laparoscopic and robotic MILS throughout Europe are lacking. METHODS: An anonymous survey consisting of 46 questions was sent to all members of the European-African Hepato-Pancreato-Biliary Association. RESULTS: The survey was completed by 120 surgeons from 103 centers in 24 countries. Median annual center volume of liver resection was 100 [IQR 50-140]. The median annual volume of MILS per center was 30 [IQR 16-40]. For minor resections, laparoscopic MILS was used by 80 (67%) surgeons and robotic MILS by 35 (29%) surgeons. For major resections, laparoscopic MILS was used by 74 (62%) surgeons and robotic MILS by 33 (28%) surgeons. The majority of the surgeons stated that minimum annual volume of MILS per center should be around 21-30 procedures/year. Of the surgeons performing robotic surgery, 28 (70%) felt they missed specific equipment, such as a robotic-CUSA. Seventy (66%) surgeons provided a formal MILS training to residents and fellows. In 5 years' time, 106 (88%) surgeons felt that MILS would have superior value as compared to open liver surgery. CONCLUSION: In the participating European liver centers, MILS comprised about one third of all liver resections and is expected to increase further. Laparoscopic MILS is still twice as common as robotic MILS. Development of specific instruments for robotic liver parenchymal transection might further increase its adoption.

Stepwise implementation of robotic surgery in a high volume HPB practice in the Netherlands.

BACKGROUND: Aims of this study were to describe the stepwise implementation and expansion of robotic HPB surgery in a high volume HPB unit in the Netherlands and to analyze clinical outcomes of all robotic liver resections and robotic pancreatoduodenectomies performed within this program. METHODS: After proctoring by expert international surgeons, HPB surgeons were introduced to robotic liver resection and robotic pancreatoduodenectomy in a stepwise fashion. Data from two prospective databases containing all consecutive patients who underwent robotic liver resection or robotic pancreatoduodenectomy between August 1st, 2015 and March 1st, 2019 were analyzed post hoc. RESULTS: In total, 77 consecutive robotic liver resections and 68 consecutive robotic pancreatoduodenectomies were performed. Five surgeons were consecutively introduced to robotic HPB surgery. Mean operative time for robotic liver resection was 160 ± 78 min. Mean operative time for robotic pancreatoduodenectomy was 420 ± 67 min. Operative times remained stable over time and were not affected by the introduction of new surgeons. CONCLUSION: Stepwise implementation and expansion of robotic HPB surgery within one unit over a three-and-half year period is feasible and associated with good clinical outcomes. Despite introducing new surgeons to the technique, operative times, an indicator of the learning process, remained stable over time.

Robotic Versus Open Minor Liver Resections of the Posterosuperior Segments: A Multinational, Propensity Score-Matched Study.

BACKGROUND: Minor liver resections of posterosuperior segments (1, 4A, 7, 8) are challenging to perform laparoscopically and are mainly performed using an open approach. We determined the feasibility of robotic resections of posterosuperior segments and compared short-term outcomes with the open approach. METHODS: Data on open and robotic minor (≤ 3 segments) liver resections including the posterosuperior segments, performed between 2009 and 2016, were collected retrospectively from four hospitals. Robotic and open liver resections were compared, before and after propensity score matching. RESULTS: In total, 51 robotic and 145 open resections were included. After matching, 31 robotic resections were compared with 31 open resections. Median hospital stay was 4 days (interquartile range [IQR] 3-7) for the robotic group, versus 8 days (IQR 6-10) for the open group (p < 0.001). Median operative time was 222 min (IQR 164-505) for robotic cases versus 231 min (IQR 190-301) for open cases (p = 0.668). Median estimated blood loss was 200 mL (IQR 100-400) versus 300 mL (IQR 125-750), respectively (p = 0.212). In the robotic group, one patient (3%) had a major complication, versus three patients (10%) in the open group (p = 0.612). Readmissions were similar-10% in the robotic group versus 6% in the open group (p > 0.99). There was no mortality in either group. CONCLUSION: Minor robotic liver resections of the posterosuperior segments are safe and feasible and display a shorter length of stay than open resections in selected patients at expert centers.

Implementation and outcome of minor and major minimally invasive liver surgery in the Netherlands.

BACKGROUND: While most of the evidence on minimally invasive liver surgery (MILS) is derived from expert centers, nationwide outcomes remain underreported. This study aimed to evaluate the implementation and outcome of MILS on a nationwide scale. METHODS: Electronic patient files were reviewed in all Dutch liver surgery centers and all patients undergoing MILS between 2011 and 2016 were selected. Operative outcomes were stratified based on extent of the resection and annual MILS volume. RESULTS: Overall, 6951 liver resections were included, with a median annual volume of 50 resections per center. The overall use of MILS was 13% (n = 916), which varied from 3% to 36% (P < 0.001) between centers. The nationwide use of MILS increased from 6% in 2011 to 23% in 2016 (P < 0.001). Outcomes of minor MILS were comparable with international studies (conversion 0-13%, mortality <1%). In centers which performed ≥20 MILS annually, major MILS was associated with less conversions (14 (11%) versus 41 (30%), P < 0.001), shorter operating time (184 (117-239) versus 200 (139-308) minutes, P = 0.010), and less overall complications (37 (30%) versus 58 (42%), P = 0.040). CONCLUSION: The nationwide use of MILS is increasing, although large variation remains between centers. Outcomes of major MILS are better in centers with higher volumes.

Oncologic outcomes after robot-assisted versus laparoscopic distal pancreatectomy: Analysis of the National Cancer Database.

BACKGROUND: How the oncologic outcomes after robotic distal pancreatectomy (RDP) compare to those after laparoscopic distal pancreatectomy (LDP) remains unknown. METHODS: Using the National Cancer Database (NCDB), we analyzed all patients undergoing LDP or RDP for resectable pancreatic adenocarcinoma over a 4-year period (2010-2013). RESULTS: Of the 704 eligible patients, 605 (86%) underwent LDP and 99 (14%) underwent RDP. The median follow-up for patients was 25 months. There were no differences in the two groups with respect to sociodemographic, clinicopathologic, or treatment characteristics. On comparing LDP versus RDP, there was no difference in the margin-positive rate (15% vs 16%; P = 0.84); lymph nodes examined (12 vs 11; P = 0.67); overall survival (hazard ratio [HR], 1.1, 95% confidence intervals [CI], 0.7 to 1.7; 28 vs 25 months; P = 0.71); hospital stay (6 vs 5 days; P = 0.14); time to chemotherapy (50 vs 52 days; P = 0.65); 30-day readmission (9.4% vs 9.1%; P = 0.92); and mortality (1% vs 0%; P = 0.28). Patients undergoing LDP had a significantly higher conversion rate to open or minimally invasive pancreatic cancer resections compared with RDP (27% vs 10%; P < 0.001). CONCLUSION: The early national experience with RDP demonstrates similar oncologic outcomes to LDP, with a significantly lower conversion rate.

Robotic liver resection including the posterosuperior segments: initial experience.

BACKGROUND: Robot-assisted laparoscopy has been introduced to overcome the limitations of conventional laparoscopy. This technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. Therefore, improved dexterity may make a robotic system particularly suited for liver resections, which require nonlinear manipulation, such as curved parenchymal transection, hilar dissection, and resection of posterosuperior segments. METHODS: Between August 2014 and March 2016, 16 patients underwent robot-assisted laparoscopic liver resection at University Medical Center Utrecht. RESULTS: Fifteen robot-assisted laparoscopic liver resections were performed in a minimally invasive manner. One procedure was converted. In eight patients, we performed a resection of a posterosuperior segment (segment 7 or 8). Median operating time was 146 (60-265) min, and median blood loss was 150 (5-600) mL. Four patients had a Clavien-Dindo grade III complication. Median length of stay was 4 (1-8) days. There was no mortality. CONCLUSIONS: This prospective study reporting on our initial experience with robot-assisted laparoscopic liver resection demonstrates that this technique is easily adopted, safe, and feasible for minor hepatectomies in selected patients. Moreover, it shows that the robotic platform also enables fully laparoscopic resections of the posterior segments.

Robot-assisted laparoscopic liver resection: a systematic review and pooled analysis of minor and major hepatectomies.

BACKGROUND: Robotic surgery has been introduced to overcome the limitations of conventional laparoscopy. A systematic review and meta-analysis were performed to assess the safety and feasibility for three subgroups of robot-assisted laparoscopic liver resection: (i) minor resections of easily accessible segments: 2/3, 4B, 5, 6, (ii) minor resections of difficult located segments: 1, 4A, 7, 8 and (iii) major resections: ≥ 4 segments. METHODS: A systematic search was performed in PubMed, EMBASE and Cochrane Library. RESULTS: Twelve observational, mostly retrospective studies reporting on 363 patients were included. Data were pooled and analyzed. For subgroup (i) (n = 81) the weighted mean operative time was 215 ± 65 min. One conversion (1%) to laparotomy was needed. Weighted mean operative time for subgroup (ii) (n = 17) was 220 ± 60 min. No conversions were needed. For subgroup (iii) (n = 99) the weighted mean operative time was 405 ± 100 min. In this subgroup 8 robotic procedures (8%) were converted to open surgery. CONCLUSION: Data show that robot-assisted laparoscopic liver resection is feasible in minor resections of all segments and major resections. Larger, prospective studies are warranted to compare the possible advantages of robot-assisted surgery with conventional laparoscopy and open surgery.

Robotic distal pancreatectomy for a neuroendocrine tumor in an 11-year-old child.

INTRODUCTION: Over the past decade, robotic pancreatic surgery has gained popularity. Although anatomically comparable, the small size of pediatric patients might impede the use of the surgical robot due to the size of the robotic arms. Pediatric pancreatic resection is rarely indicated, hence only few cases of pediatric robotic pancreatic resection have been described (Hagendoorn et al., 2018; Lalli Raj, 2019-4) [1,2]. To the best our knowledge, no video literature exists on robotic pediatric pancreatic tail resections. Aim of this video was to demonstrate the set-up and surgical technique of robotic distal pancreatectomy in a child. METHODS: This video illustrates fully robotic distal pancreatectomy in an eleven-year-old child. The patient had a past medical history of tuberous sclerosis complex. On surveillance imaging a non-functional neuroendocrine tumor was detected in the pancreatic tail for which a distal pancreatectomy was indicated. RESULTS: After general anesthesia, the patient was placed in supine position on a split-leg table in anti-Trendelenburg. Four robotic trocars were placed and the da Vinci Xi robotic system was docked. Two laparoscopic assistant ports were placed. A spleen-preserving distal pancreatectomy was performed. Postoperative recovery was unremarkable and the patient was discharged on postoperative day 6. CONCLUSION: This video illustrates robotic distal pancreatectomy in an eleven-year-old child. Meticulous port placement, adjusted to the patient's habitus, is an essential element.

Robotic liver resection of segment 7: A step-by-step description of the technique.

BACKGROUND: Robotic surgery is increasingly employed in complex procedures such as liver resection. Minor resections of the posterosuperior segments might benefit in particular from a robotic approach, since the size of the incision dominates the postoperative recovery rather than the extent of the resection [1]. We aimed to provide a standardized, step-wise guide to robotic liver resection of segment 7. METHODS: This video illustrates, step-by-step, robotic segment 7 resection. Patients are placed in left lateral position, slight anti-Trendelenburg. Three robotic ports are used and one conventional laparoscopic port is placed for bedside assistance. Next, segment 7 is mobilized. Intraoperative ultrasound is used to delineate the tumor and ensure a safe oncologic margin. The EndoWrist ® One™ Vessel Sealer (Extend) (Intuitive Surgical Inc., Sunnyvale, CA, USA) is used for transection of the hepatic parenchyma, combined with a bipolar Maryland Forceps (Intuitive Surgical, Sunnyvale, California, USA). Hem-o-lok clips (Teleflex Inc., Morrisville, NC, USA) or laparoscopic staplers (Medtronic, Minneapolis, MN, USA) are used to control the hepatic pedicle. A pringle manoeuvre is applied when deemed appropriate. To ensure hemostasis and biliostasis, TachoSil (Takeda Nederland b.v. Takeda, Zurich, Switzerland) is applied to the resection surface. The specimen is extracted through an enlarged trocar incision. RESULTS: This video illustrates robotic liver resection of segment 7 in a 72-year-old male with a past medical history of colorectal cancer. New, resectable liver metastases were detected during follow-up. The procedure was completed fully robotically. No postoperative complications occurred and the patient was discharged on postoperative day one. CONCLUSION: This video provides a step-by-step guide to robotic liver resection of segment 7.

Robotic right hepatectomy for a central liver tumor- A video of the surgical technique.

BACKGROUND: Robotic surgery is gaining momentum in liver resection. Instrumentation of the surgical robot is articulated, movements are scaled and the view of the operative field is 3-dimensional and magnified[1, 2]. Thus, these technical enhancements allow for a more precise dissection and curved work axes, as needed in liver resection. Aim of this video was to demonstrate the feasibility of fully robotic right hepatectomy with dissection of the variant right hepatic pedicles for a centrally located liver tumor. METHODS: This video illustrates robotic right hepatectomy in a 77-year-old male. A liver tumor in segment 5/8 with concurrent biliary dilation was detected on a CT-scan made in the course of his cardiac history. An additional MRI scan suggested the diagnosis of hepatocellular carcinoma or intrahepatic cholangiocarcinoma for which a right hepatectomy was indicated. RESULTS: After anesthesia, the patient was placed supine on a split-leg table in anti-Trendelenburg and left lateral tilt position. Four robotic trocars were placed and the da Vinci Xi robotic system was docked. Two laparoscopic ports were placed for tableside assistance. Right hepatectomy was performed including separate dissection of the posterior and anterior pedicles. The robotic Vessel Sealer was employed as main parenchymal transection device. Postoperative hospital stay was unremarkable. The patient was discharged on postoperative day 6. CONCLUSION: This video illustrates the feasibility of a robotic approach to right hepatectomy. The increased surgical dexterity, as provided by the articulating robotic instrumentation, allows for precise dissection of the liver hilum, as needed in resection of centrally located tumors.

Robotic Developments in Cancer Surgery.

Indications for robotic surgery have been rapidly expanding since the first introduction of the robotic surgical system in the US market in 2000. As the robotic systems have become more sophisticated over the past decades, there has been an expansion in indications. Many new tools have been added with the aim of optimizing outcomes after oncologic surgery. Complex abdominal cancers are increasingly operated on using robot-assisted laparoscopy and with acceptable outcomes. In this article, the authors discuss robotic developments, from the past and the future, with an emphasis on cancer surgery.

[Robot-assisted Whipple resection; results of the first 100 procedures in the Netherlands]. / Robotgeassisteerde Whipple-operatie.

OBJECTIVE: Investigation into the results of robot-assisted Whipple resection in the Netherlands. These results were compared with those of open Whipple procedures on the basis of recent large case series of patients. DESIGN: Case series of patients and systematic literature review. METHOD: We carried out a post hoc analysis of prospectively collected data on the first 100 consecutive patients who underwent robot-assisted Whipple procedures in the period from March 2016 until March 2018 at the Erasmus MC, the Maasstad hospital or the Regional Academic Cancer Centre Utrecht. We were mainly interested in surgery characteristics and postoperative outcomes. We compared our results with those of case series of patients with more than 500 open Whipple procedures carried out in a single hospital, published in the last 5 years. RESULTS: There were one or more serious complications in 22 patients (22%) and 2 patients (2%) developed multiple organ failure. 7 patients (7%) underwent reoperation. There was no postoperative mortality. In 14 case series (n = 12,708), complications occurred in 38% of patients and 7% of patients underwent reoperation. Mean mortality rate was 3%. CONCLUSION: Our findings show that robotic Whipple procedures can be carried out safely in the Netherlands. The number of complications and mortality rates are comparable with results of large case series of patients who underwent open Whipple procedures in a centre of expertise.

Robotic pancreatoduodenectomy for a solid pseudopapillary tumor in a ten-year-old child.

BACKGROUND: Pancreatoduodenectomy (Whipple resection) in children is feasible though rarely indicated. In several pediatric malignancies of the pancreas, however, it may be the only curative strategy [1]. With the emergence of robotic pancreatoduodenectomy as at least a clinically equivalent alternative to open surgery [2], it remains to be determined whether the pediatric population may potentially benefit from this minimally invasive procedure. Here we present, for the first time, a video of setup and surgical technique of robotic pancreatoduodenectomy in a child. METHODS: A 10-year-old girl presented with complaints of fullness and abdominal pain in the upper quadrants. Investigations including a diffusion-weighted, pancreatic MR scan suggested the diagnosis of solid pseudopapillary tumor (Frantz's tumor). The patient was considered for robotic pancreatoduodenectomy. RESULTS: After anesthesia, the patient was placed supine on a split-leg table. Trocar placement was adjusted to accommodate the child's length and body weight, according to pre-operatively calculated positions that would allow for maximum working space and minimize inadvertent collision between the robotic arms. The da Vinci Si surgical robot was positioned in-line towards the surgical target and all four robotic arms were docked, while two additional laparoscopic ports were placed for tableside assistance. After standard pancreatoduodenectomy, a conventional loop reconstruction was performed including an end-to-side pancreaticojejunostomy with duct-to-mucosa technique and stapled side-to-side gastrojejunostomy. We suggest that in this patient group, pylorus preserving pancreatoduodenectomy with end-to-side duodenojejunostomy may be a suitable alternative. Postoperative recovery was complicated by delayed gastric emptying but otherwise unremarkable. Hospital length of stay was 12 days. Final pathology demonstrated a solid pseudopapillary tumor with negative surgical margins. CONCLUSION: This case illustrates the feasibility of robotic pancreatoduodenectomy in children. Essential elements of this procedure are a well-running robotic pancreatic surgery program as well as careful preoperative port placement planning.

Setting up a robotic hepatectomy program: a Western-European experience and perspective.

Currently the majority of liver resections are performed via open resection. Nevertheless, minimally invasive liver surgery is gaining ground and conventional laparoscopy has proven to be beneficial in different fields of liver surgery compared to open resections. Still, conventional laparoscopy has a few downsides, from which straight instruments, 2-dimensional view and awkward ergonomics are the most obvious. The robotic surgical system is developed to overcome these limitations. It offers several advantages over conventional laparoscopy to optimize conditions in minimally invasive surgery: instruments are wristed with a wide range of motion and the view is 3-dimensional and magnified. With instruments with a greater range of motion than in laparoscopic surgery, the use of a robotic system potentially broadens indications for minimally invasive liver resection. Here, we discuss the steps of setting up a robotic hepatectomy program against the background of the initial experience at our institution.

Developing a robotic pancreas program: the Dutch experience.

Robot-assisted surgery has been developed to overcome limitations of conventional laparoscopy aiming to further optimize minimally invasive surgery. Despite the fact that robotics already have been widely adopted in urology, gynecology, and several gastro-intestinal procedures, like colorectal surgery, pancreatic surgery lags behind. Due to the complex nature of the procedure, surgeons probably have been hesitant to apply minimally invasive techniques in pancreatic surgery. Nevertheless, the past few years pancreatic surgery has been catching up. An increasing number of procedures are being performed laparoscopically and robotically, despite it being a highly complex procedure with high morbidity and mortality rates. Since the complex nature and extensiveness of the procedure, the start of a robotic pancreatic program should be properly prepared and should comply with several conditions within high-volume centers. Robotic training plays a significant role in the preparation. In this review we discuss the different aspects of preparation when working towards the start of a robotic pancreas program against the background of our nationwide experience in the Netherlands.

Robot-assisted Laparoscopic Fenestration of Giant Hepatic Cysts.

BACKGROUND: Traditionally, nonparasitic hepatic cysts are marsupialized using laparotomy. In the last 2 decades, laparoscopic fenestration has become the preferred treatment for hepatic cysts. However, this technique is limited by 2-dimensional view and the limited mobility of straight laparoscopic instruments. These limitations may be overcome by the use of a robotic system. We describe laparoscopic fenestration of giant hepatic cysts using the da Vinci Si robotic system with the use of the Endowrist One Vessel Sealer. METHODS: Our first patient is a 32-year-old female with a solitary hepatic cyst. The second patient is a 51-year-old female with polycystic liver disease. RESULTS: We performed robot-assisted laparoscopic cyst fenestration with good clinical outcome. No intraoperative complications occurred and patients recovered rapidly. CONCLUSION: These data show that the da Vinci Si robotic system is eminently suited for the laparoscopic fenestration of large hepatic cysts and that this procedure is associated with rapid recovery.