Robotic Versus Laparoscopic Liver Resection in Various Settings: An International Multicenter Propensity Score Matched Study of 10.075 Patients.

OBJECTIVE: To compare the perioperative outcomes of robotic liver surgery (RLS) and laparoscopic liver surgery (LLS) in various settings. BACKGROUND: Clear advantages of RLS over LLS have rarely been demonstrated, and the associated costs of robotic surgery are generally higher than those of laparoscopic surgery. Therefore, the exact role of the robotic approach in minimally invasive liver surgery remains to be defined. METHODS: In this international retrospective cohort study, the outcomes of patients who underwent RLS and LLS for all indications between 2009 and 2021 in 34 hepatobiliary referral centers were compared. Subgroup analyses were performed to compare both approaches across several types of procedures: (1) minor resections in the anterolateral (2, 3, 4b, 5, and 6) or (2) posterosuperior segments (1, 4a, 7, 8), and (3) major resections (≥3 contiguous segments). Propensity score matching was used to mitigate the influence of selection bias. The primary outcome was textbook outcome in liver surgery (TOLS), previously defined as the absence of intraoperative incidents ≥grade 2, postoperative bile leak ≥grade B, severe morbidity, readmission, and 90-day or in-hospital mortality with the presence of an R0 resection margin in case of malignancy. The absence of a prolonged length of stay was added to define TOLS+. RESULTS: Among the 10.075 included patients, 1.507 underwent RLS and 8.568 LLS. After propensity score matching, both groups constituted 1.505 patients. RLS was associated with higher rates of TOLS (78.3% vs 71.8%, P < 0.001) and TOLS+ (55% vs 50.4%, P = 0.026), less Pringle usage (39.1% vs 47.1%, P < 0.001), blood loss (100 vs 200 milliliters, P < 0.001), transfusions (4.9% vs 7.9%, P = 0.003), conversions (2.7% vs 8.8%, P < 0.001), overall morbidity (19.3% vs 25.7%, P < 0.001), and microscopically irradical resection margins (10.1% vs. 13.8%, P = 0.015), and shorter operative times (190 vs 210 minutes, P = 0.015). In the subgroups, RLS tended to have higher TOLS rates, compared with LLS, for minor resections in the posterosuperior segments (n = 431 per group, 75.9% vs 71.2%, P = 0.184) and major resections (n = 321 per group, 72.9% vs 67.5%, P = 0.086), although these differences did not reach statistical significance. CONCLUSIONS: While both produce excellent outcomes, RLS might facilitate slightly higher TOLS rates than LLS.

Unplanned conversions of robotic pancreaticoduodenectomy: short-term outcomes and suggested stepwise approach for a safe conversion.

OBJECTIVE: With the increased adoption of robotic pancreaticoduodenectomy, the effects of unplanned conversions to an 'open' operation are ill-defined. This study aims to describe the impact of unplanned conversions of robotic pancreaticoduodenectomy on short-term outcomes and suggest a stepwise approach for safe unplanned conversions during robotic pancreaticoduodenectomy. METHODS: This is an analysis of 400 consecutive patients undergoing robotic pancreaticoduodenectomy in a single high-volume institution. Data are presented as median (mean ± SD), and significance is accepted with 95% probability. RESULTS: Between November 2012 and February 2023, 184 (46%) women and 216 (54%) men, aged 70 (68 ± 11.0) years, underwent a robotic pancreaticoduodenectomy. Unplanned conversions occurred in 42 (10.5%) patients; 18 (5%) were converted due to unanticipated vascular involvement, 13 (3%) due to failure to obtain definitive control of bleeding, and 11 (3%) due to visceral obesity. Men were more likely to require a conversion than women (29 vs. 13, p = 0.05). Conversions were associated with shorter operative time (376 (323 ± 182.2) vs. 434 (441 ± 98.7) min, p < 0.0001) but higher estimated blood loss (675 (1010 ± 1168.1) vs. 150 (196 ± 176.8) mL, p < 0.0001). Patients that required an unplanned conversion had higher rates of complications with Clavien-Dindo scores of III-V (31% vs. 12%, p = 0.003), longer length of stay (8 (11 ± 11.6) vs. 5 (7 ± 6.2), p = 0.0005), longer ICU length of stay (1 (2 ± 5.1) vs. 0 (0 ± 1.3), p < 0.0001) and higher mortality rates (21% vs. 4%, p = 0.0001). The conversion rate significantly decreased over time (p < 0.0001). CONCLUSIONS: Unplanned conversions of robotic pancreaticoduodenectomy significantly and negatively affect short-term outcomes, including postoperative mortality. Men were more likely to require a conversion than women. The unplanned conversions rates significantly decreased over time, implying that increased proficiency and patient selection may prevent unplanned conversions. An unplanned conversion should be undertaken in an organized stepwise approach to maximize patient safety.

Outcomes after pancreaticoduodenectomy with or without preoperative hyperbaric oxygen therapy.

Background: Hyperbaric oxygen (HBO2) therapy is an alternative method against the deleterious effects of ischemic/reperfusion (I/R) injury and its inflammatory response. This study assessed the effect of preoperative HBO2 on patients undergoing pancreaticoduodenectomy. Study Design: Patients were randomized via a computer-generated algorithm. Patients in the HBO2 cohort received two sessions of HBO2 the evening before and the morning of surgery. Measurements of inflammatory mediators and self-assessed pain scales were determined pre-and postoperatively. In addition, perioperative variables and long-term survival were collected and analyzed. Data are presented as median (mean ± SD). Results: 33 patients were included; 17 received preoperative HBO2, and 16 did not. There were no intraoperative or postoperative statistical differences between patients with or without preoperative HBO2. Erythrocyte sedimentation rate (ESR), IL-6, and IL-10 increased slightly before returning to normal, while TGF-alpha decreased before increasing. However, there were no differences with or without HBO2. At postoperative day 30, the pain level measured with VAS score (Visual Analog Score) was lower after HBO2 (1 ± 1.3 vs. 3 ± 3.0, p=0.05). Eleven (76%) patients in the HBO2 cohort and 12 (75%) patients in the non- HBO2 had malignant pathology. The percentage of positive lymph nodes in the HBO2 was 7% compared to 14% in the non-HBO2 (p<0.001). Overall survival was inferior after HBO2 compared to the non- HBO2 (p=0.03). Conclusions: Preoperative HBO2 did not affect perioperative outcomes or significantly change the inflammatory mediators for patients undergoing robotic pancreaticoduodenectomy. Long-term survival was inferior after preoperative HBO2. Further randomized controlled studies are required to assess the full impact of this treatment on patients' prognosis.

Does metabolic syndrome affect perioperative outcomes in patients undergoing robotic hepatectomy? A propensity score-matched analysis.

BACKGROUND: Metabolic syndrome is a known risk factor for postoperative complications after general surgical procedures. Literature analyzing perioperative outcomes of patients with metabolic syndrome undergoing a minimally invasive hepatectomy is limited. We sought to investigate if metabolic syndrome significantly impacts the perioperative course and outcomes of patients undergoing robotic hepatectomy. METHODS: With IRB, we prospectively followed patients who underwent robotic hepatectomy from 2016 through 2020. A 1:1 propensity score-matched (PSM) analysis was applied to patients with and without metabolic syndrome. Demographic and clinical data were analyzed for those cohorts before and after PSM. Metabolic syndrome was defined as BMI ≥ 28.8 kg/m2, diabetes, and hypertension. RESULTS: A total of 272 patients underwent robotic hepatectomy, 39 (14%) of whom had metabolic syndrome. After performing PSM, we ended up with 74 patients, 37 in each cohort, 28% of them had liver cirrhosis. Patients with metabolic syndrome had higher BMI (34 ± 5.6 vs. 28 ± 5.9 kg/m2, p < 0.001) and MELD scores (10 ± 4.5 vs. 8 ± 3.2, p < 0.001) compared to patients without metabolic syndrome. Additionally, patients with metabolic syndrome had an increased incidence of liver cirrhosis (33% vs. 9%, p = 0.0002). Following PSM, BMI (34 ± 5.7 vs. 26 ± 4.4 kg/m2, p < 0.001) was the only preoperative variables associated with metabolic syndrome. There were no statistical differences before and after PSM between patients with and without metabolic syndrome in terms of intraoperative metrics including operative time, blood loss, conversion to 'open,' and intraoperative complications. All postoperative outcomes metrics before and after PSM did not correlate with the presence or absence of metabolic syndrome. CONCLUSIONS: Metabolic syndrome had no impact on intra- or postoperative metrics, complications, or outcomes after robotic hepatectomy. We believe that the robotic approach may mitigate the adverse effects of metabolic syndrome for patients undergoing robotic hepatectomy.

Validity of the Institut Mutualiste Montsouris classification system for robotic liver resection.

BACKGROUND: The Institut Mutualiste Montsouris (IMM) classification system is one of several widely accepted difficulty scoring systems for laparoscopic liver resections. Nothing is yet known about the applicability of this system for robotic liver resections. METHODS: We conducted a retrospective review of 359 patients undergoing robotic hepatectomies between 2016 and 2022. Resections were classified into low, intermediate, and high difficulty level. Data were analyzed utilizing ANOVA of repeated measures, 3 x 2 contingency tables, and area under the receiving operating characteristic (AUROC) curves. Data are presented as median (mean ± SD). RESULTS: Of the 359 patients, 117 were classified as low-difficulty level, 92 as intermediate, and 150 as high. The IMM system correlates well with tumor size (p = 0.002). The IMM system was a strong predictor of intraoperative outcomes including operative duration (p<0.001) and estimated blood loss (EBL) (p<0.001). The IMM system also showed a strong calibration for predicting an open conversion (AUC=0.705) and intraoperative complications (AUC=0.79). In contrast, the IMM system was a poor predictor of postoperative complications, mortality, and readmission. CONCLUSION: The IMM system provides a strong correlation with intraoperative, but not postoperative outcomes. A dedicated difficulty scoring system should be developed for robotic hepatectomy.

Robotic Extrahepatic Biliary Resection with Roux-en-Y Hepaticojejunostomy for Type 2 Klatskin Tumor.

BACKGROUND: Despite the widespread of laparoscopic technique in hepatobiliary tumor resection, nearly all Klatskin tumor resection is undertaken using an open approach (Marino et al. in Updates Surg 72(3):911-912. https://doi.org/10.1007/s13304-020-00777-8 ; Sucandy et al. in Am Surg, 2020. https://doi.org/10.1177/0003134820956336 , Am Surg, 2020;86(3):200-207; Luberice et al. in HPB (Oxford), 2020. https://doi.org/10.1016/j.hpb.2020.10.008 ; Ciria et al. in J Hepatobiliary Pancreat Sci, 2020. https://doi.org/10.1002/jhbp.869 ; Chong and Choi in J Gastrointest Surg 23(9):1947-19488, 2019. https://doi.org/10.1007/s11605-019-04242-9 ). A minimally invasive approach for malignant extrahepatic biliary resection is rarely used due to technical complexity and concerns of oncological inferiority. In the United States, robotic technique for Klatskin tumor resection has not been adequately described. This video described our technique of robotic extrahepatic biliary resection with Roux-en-Y hepaticojejunostomy (HJ) for type 2 Klatskin tumor. METHODS: A 77-year-old man presented with obstructive jaundice. Endobiliary brushing confirmed adenocarcinoma. MRI/MRCP showed a focal lesion at the cystic duct entrance into the common hepatic duct, extending cephalad toward the biliary bifurcation. No obvious vascular invasion was identified on the CT scan. RESULTS: The operation was undertaken using a six-port technique. Systematic portal dissection was undertaken to identify the bile duct at the level of the pancreas up toward the hepatic hilum. A partial Kocher maneuver was performed to expose the area dorsal to the distal common bile duct, which allows for a more thorough lymphadenectomy and facilitates creation of a later tension-free hepaticojejunostomy. The distal common bile duct was transected, and the distal margin was sent for frozen section. The right hepatic artery coursing posterior to the common hepatic duct was skeletonized and preserved. Biliary duct bifurcation was transected at the level of the right and left duct, removing the cancer completely. Portal lymphadenectomy was completed as part of oncological staging and treatment. A total of eight lymph nodes were removed and all confirmed to be nonneoplastic on the final pathology report. For the purpose of the biliary reconstruction, a standard side-to-side stapled jejunojejunostomy was created. A jejunal mesenteric defect was closed to prevent a future internal herniation. A 60-cm Roux limb was transposed antecolically for the Roux-en-Y hepaticojejunostomy. A running technique was used to create a watertight end-to-side bilioenteric anastomosis, using 3-0 barbed sutures, 6 inches in length. A closed suction drain was placed before closing. Pathology report confirmed intraductal papillary adenocarcinoma with R-0 resection margins (proximal, distal, and radial margin). Perineural invasion was present; however, lymphovascular invasion was not identified. Total operative time was 240 minutes with 75 ml of estimated blood loss. The postoperative recovery was uneventful. One-year follow-up showed no evidence of disease recurrence or HJ anastomotic stricture. CONCLUSIONS: This video demonstrates a safe and feasible application of the robotic platform in extrahepatic bile duct cancer resection requiring fine biliary reconstruction.

Robotic resection of extrahepatic cholangiocarcinoma: Institutional outcomes of bile duct cancer surgery using a minimally invasive technique.

BACKGROUND AND OBJECTIVES: The purpose of this study is to report our early experience and outcomes, the first in North America, of Extrahepatic Cholangiocarcinoma (EHC) resection with Roux-en Y Hepaticojejunostomy reconstruction via the robotic approach. METHODS: With Institutional Review Board approval, 15 patients who underwent robotic resection of EHC were studied. RESULTS: Patients were 74 (73 ± 8.9) years of age. There were 9 men and 6 women. Average body mass index was 24 (27 ± 6.3) kg·m-2 . Mean & Median ASA class was 3. Median Tumor size was 2 (2 ± 1.3) cm. There were no intraoperative complications. Operative duration was 453 (443 ± 85.0) minutes and the estimated blood loss was 150 (182 ± 138.4) ml. No patient required admission to the intensive care unit. Hospital length of stay was 4 (6 ± 3.2) days. There was one patient with Clavien-Dindo Class 3 or greater complication. No mortality was seen in this series. DISCUSSION: Robotic resection of EHC is safe, feasible, and reproducible with excellent clinical outcomes. Consequently, the robotic technique should be considered in some patients requiring EHC resection.

Propensity score matched comparison of robotic and open major hepatectomy for malignant liver tumors.

BACKGROUND: Outcome data on robotic major hepatectomy are lacking. This study was undertaken to compare robotic vs. 'open' major hepatectomy utilizing patient propensity score matching (PSM). METHODS: With institutional review board approval, we prospectively followed 183 consecutive patients who underwent robotic or 'open' major hepatectomy, defined as removal of three or more Couinaud segments. 42 patients who underwent 'open' approach were matched with 42 patients who underwent robotic approach. The criteria for PSM were age, resection type, tumor size, tumor type, and BMI. Survival was individually stratified for hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (IHCC), and colorectal liver metastases (CLM). The data are presented as: median (mean ± SD). RESULTS: Operative duration for the robotic approach was 293 (302 ± 131.5) vs. 280 (300 ± 115.6) minutes for the 'open' approach (p = NS). Estimated Blood Loss (EBL) was 200 (239 ± 183.6) vs. 300 (491 ± 577.1) ml (p = 0.01). There were zero postoperative complications with a Clavien-Dindo classification ≥ III for the robotic approach and three for the 'open' approach (p = NS). ICU length of stay (LOS) was 1 (1 ± 0) vs. 2 (3 ± 2.0) days (p = 0.0001) and overall LOS was 4 (4 ± 3.3) vs. 6 (6 ± 2.7) days (p = 0.003). In terms of long-term oncological outcomes, overall survival was similar for patients with IHCC and CLM regardless of the approach. However, patients with HCC who underwent robotic resection lived significantly longer (p = 0.05). CONCLUSION: Utilizing propensity score matched analysis, the robotic approach was associated with a lower EBL, shorter ICU LOS, and shorter overall LOS while maintaining similar operative duration and promoting survival in patients with HCC. We believe that the robotic approach is safe and efficacious and should be considered a preferred alternative approach for major hepatectomy.

Analysis of survival outcomes following robotic hepatectomy for malignant liver diseases.

BACKGROUND: Despite increased adoption of the robotic platform for complex hepatobiliary resections for malignant disease, little is known about long-term survival outcomes. This is the first study to evaluate the postoperative outcomes, and short- and long-term survival rates after a robotic hepatectomy for five major malignant disease processes. METHODS: A prospectively collected database of patients who underwent a robotic hepatectomy for malignant disease was reviewed. Pathologies included colorectal liver metastases (CLM), hepatocellular carcinoma (HCC), Klatskin tumor, intrahepatic cholangiocarcinoma (IHCC), and gallbladder cancer (GC). Data are presented as median (mean â€‹± â€‹standard deviation) for illustrative purposes. RESULTS: Of the 210 consecutive patients who underwent robotic hepatectomy for malignant disease, 75 (35 â€‹%) had CLM, 69 (33 â€‹%) had HCC, 27 (13 â€‹%) had Klatskin tumor, 20 (10 â€‹%) had IHCC, and 19 (9 â€‹%) had GC. Patients were 66 (65 â€‹± â€‹12.4) years old with a BMI of 29 (29 â€‹± â€‹6.5) kg/m2. R0 resection was achieved in 91 â€‹%, and 65 â€‹% underwent a major hepatectomy. Postoperative major complication rate was 6 â€‹%, length of stay was four (5 â€‹± â€‹4.3) days, and 30-day readmission rate was 17 â€‹%. Survival at 1, 3, and 5-years were 93 â€‹%/75 â€‹%/72 â€‹% for CLM, 84 â€‹%/71 â€‹%/64 â€‹% for HCC, 73 â€‹%/55 â€‹%/55 â€‹% for Klatskin tumor, 80 â€‹%/69 â€‹%/69 â€‹% for IHCC, 79 â€‹%/65 â€‹%/65 â€‹% for GC. CONCLUSION: This study suggests a favorable 5-year overall survival benefit with use of the robotic platform in hepatic resection for colorectal metastases, hepatocellular carcinoma, intrahepatic cholangiocarcinoma, Klatskin tumor, and gallbladder cancer. The robotic platform facilitates fine dissection in complex hepatobiliary operations, with a high rate of R0 resections and excellent perioperative clinical outcomes.

Tampa Difficulty Score: a novel scoring system for difficulty of robotic hepatectomy.

BACKGROUND: Difficulty scoring system (DSS) has been established for laparoscopic hepatectomy and serves as useful tools to predict difficulty and guide preoperative planning. Despite increased adoption of robotics and its unique technical characteristics compared with laparoscopy, no DSS currently exists for robotic hepatectomy. We aimed to introduce a new DSS for robotic hepatectomy. METHODS: A total of 328 patients undergoing a robotic hepatectomy were identified. After removing the first 24 major and 30 minor hepatectomies using cumulative-sum analysis, 274 patients were included in this study. Relevant clinical variables underwent linear regression using operative time and/or estimated blood loss (EBL) as markers for operative difficulty. Score distribution was analyzed to develop a difficulty-level grouping system. RESULTS: Of the 274 patients, neoadjuvant chemotherapy; tumor location, size, and type; the extent of parenchymal resection; the need for portal lymphadenectomy; and the need for biliary resection with hepaticojejunostomy were significantly associated with operative time and/or EBL. They were used to develop the difficulty scores from 1 to 49. Grouping system results were group 1 (less demanding/beginner), 1 to 8 (n = 39); group 2 (intermediate), 9 to 24 (n = 208); group 3 (more demanding/advanced), 25 to 32 (n = 17); and group 4 (most demanding/expert), 33 to 49 (n = 10). When stratified by group, age, previous abdominal operation, Child-Pugh score, operative duration, EBL, major resection, 30-day mortality, 90-day mortality, and length of stay were significantly different among the groups. CONCLUSION: In addition to established variables in laparoscopic systems, new factors such as the need for portal lymphadenectomy and biliary resection specific to the robotic approach have been identified in this new robotic DSS. Internal and external validations are the next steps in maturing this robotic DSS.

The Implications of Readmission on Cost and Patient Outcomes Following Distal Pancreatectomy and Splenectomy.

BACKGROUND: Robotic platform usage for distal pancreatectomy and splenectomy has grown exponentially in recent years. This study aims to identify the impact of readmission following robotic distal pancreatectomy and splenectomy and to analyze the financial implications of these readmissions. METHODS: We prospectively followed 137 patients after robotic distal pancreatectomy and splenectomy. Readmission was defined as rehospitalization within 30 days post-discharge. Total cost incorporated initial and readmission hospital costs, when applicable. Outcomes were analyzed using chi-square/Fisher's exact test and Student's t test. Data are presented as median (mean ± SD). RESULTS: Of 137 patients, 20 (14%) were readmitted. Readmitted patients were 67 (66 ± 10.3) years old and had a BMI of 30 (30 ± 7.0) kg/m2; 9 (45%) had previous abdominal operations. Non-readmitted patients were 67 (62 ± 14.7) years old and had a BMI of 28 (28 ± 5.7) kg/m2; 37 (32%) had previous abdominal operations (P = NS, for all). Readmitted patients vs non-readmitted patients had operative durations of 327 (363 ± 179.1) vs 251 (293 ± 176.4) minutes (P = .10), estimated blood loss (EBL) of 90 (159 ± 214.6) vs 100 (244 ± 559.4) mL (P = .50), and tumor diameter of 3 (4 ± 2.0) vs 3 (4 ± 2.9) cm (P = 1.00). Initial length of stay (LOS) for readmitted patients vs patients who were not readmitted was 5 (5 ± 2.7) vs 4 (5 ± 3.0) days (P = 1.00); total hospital cost of those readmitted, including both admissions, was $29,095 (32,324 ± 20,227.38) vs $24,663 (25,075 ± 10,786.45) (P = .018) for those not readmitted. DISCUSSION: Despite a similar perioperative course, readmissions were associated with increased costs. We propose thorough consideration before readmission and increased patient education initiatives will reduce readmissions after robotic distal pancreatectomy and splenectomy.

Robotic Resection of Retroperitoneal Perinephric Tumor. Application of Intraurethral Indocyanine Green Injection As an Adjunct to Avoid Ureteral Injury.

The majority of retroperitoneal mass excision is performed via conventional "open" laparotomy due to concerns of technical difficulty and adequate oncological margins in cases of a malignant sarcoma. A very few cases of minimally invasive resection by laparoscopy had been reported in the literature. Despite the rapid adoption of robotic technology in general surgery and surgical oncology, the robotic technique has not been applied for this pathology. We discussed a complete resection of a large perinephric tumor using a robotic platform. To our knowledge, this is the first study to report the robotic technique of retroperitoneal tumor excision, highlighting the application and usefulness of intraurethral indocyanine green (ICG) injection.

Robotic liver resection for hepatocellular carcinoma: analysis of surgical margins and clinical outcomes from a western tertiary hepatobiliary center.

This study was undertaken to determine surgical outcomes of patients undergoing robotic hepatectomy for hepatocellular carcinoma (HCC) and to investigate the correlation between tumor distance to margin and perioperative outcomes, as well as overall survival (OS). To our knowledge, this study represents the largest series of robotic liver resection for HCC in North America. We retrospectively analyzed 58 consecutive patients who underwent robotic liver resection for HCC. Patients were further stratified by tumor distance to margin (≤ 1 mm, 1.1-9.9 mm, ≥ 10 mm) and their clinical outcomes including OS were compared. A majority of patients attained a greater than 1 mm tumor distance to margin (81%). There were no differences in tumor size between patient cohorts who attained ≤ 1 mm, 1.1-9.9 mm, and ≥ 10 mm margins. There were no differences in pre-, intra-, and postoperative outcomes among the three cohorts. Cost variables of interest were also similar. OS was highest in the > 10 mm margin cohort, and this was statistically significant at 3 and 5 years. Robotic HCC resection was associated with adequate tumor distance to margin. Wide margins ≥ 10 mm are associated with the best OS.

A Single Institution's Experience With Robotic Minor and Major Hepatectomy.

BACKGROUND: Minimally invasive liver resection is gradually becoming the preferred technique to treat liver tumors due its salutary benefits when compared with traditional "open" method. While robotic technology improves surgeon dexterity to better perform complex operations, outcomes of robotic hepatectomy have not been adequately studied. We therefore describe our institutional experience with robotic minor and major hepatectomy. MATERIALS AND METHODS: We prospectively study all patients undergoing robotic hepatectomy from 2016 to 2020. RESULTS: A total of 220 patients underwent robotic hepatectomy. 138 (63%) were major hepatectomies while 82 (37%) were minor hepatectomies. Median age was 63 (62 ± 13) years, 118 (54%) were female. 168 patients had neoplastic disease and 52 patients had benign disease. Lesion size in patients who had undergone minor hepatectomy was 2 (3 ± 2.5) cm, compared to 5 (5 ± 3.0) cm in patients who undergone major hepatectomy (P < .001). 97% of patients underwent R0 resections while none of the patients had R2 resection. Operative duration was 226 (260 ± 122.7) vs 282 (299 ± 118.7) minutes (P ≤ .05); estimated blood loss was 100 (163 ± 259.2) vs 200 (251 ± 246.7) mL (P ≤ .05) for minor and major hepatectomy, respectively. One patient had intraoperative bleeding requiring "open" conversion. Nine (4%) patients had experienced notable postoperative complications and 2 (1%) patients died postoperatively. Length of stay was 3 (5 ± 4.6) vs 4 (5 ± 2.8) days for minor vs major hepatectomy (P = .84). Reoperation and readmission rate for minor vs major hepatectomy was 1% vs 3% (P = .65) and 9% vs 10% (P = .81), respectively. DISCUSSION: Robotic major hepatectomy is safe, feasible, and efficacious with excellent postoperative outcomes.

Analysis of Oncological Outcomes After Robotic Liver Resection for Intrahepatic Cholangiocarcinoma.

BACKGROUND: Concerns regarding minimally invasive liver resection of intrahepatic cholangiocarcinoma (IHCC) include inadequate resection margins and inferior long-term overall survival (OS) when compared to an "open" approach. Limited data exists to address these issues. We aimed to compare perioperative variables, tumor distance to margin, and long-term outcomes after IHCC resection based on surgical approach (robotic vs open) in our hepatobiliary center to address these concerns. METHODS: With IRB approval, 34 patients who underwent robotic or open hepatectomy for IHCC were prospectively followed. Patients were stratified by tumor distance to resection margin (≤1 mm, 1.1-9.9 mm, ≥10 mm) for illustrative purposes and by approach (robotic vs open). Where appropriate, regression analysis and cox model of proportional hazards were utilized. Survival was stratified by margin distance and approach utilizing Kaplan-Meier curves. Data are presented as median (mean ± SD). RESULTS: Patients undergoing robotic vs open hepatectomy had similar demographics. Patients undergoing the robotic approach had significantly lower estimated blood loss (EBL). Tumor distance to margin between the two approaches were similar (P = .428). Median OS between the two approaches was similar in patients of any margin distance.In the subgroup analysis by margin distance, the robotic approach yielded less EBL for patients in the 1.1-9.9 mm and ≥10 mm margin groups, and a shorter ICU length of stay for patients with ≥10 mm margin. DISCUSSION: Similar margins were attained via either approach, translating into oncological non-inferiority of robotic IHCC resection. Robotic approach for the treatment of IHCC should be considered an alternative to an open approach.

A propensity score matched analysis of robotic and open hepatectomy for treatment of liver tumors. Clinical outcomes, oncological survival, and costs comparison.

Minimally invasive robotic hepatectomy is gaining popularity with a faster rate of adoption when compared to laparoscopic approach. Technical advantages brought by the robotic surgical system facilitate a transition from open to minimally invasive technique in hepatic surgery. Published matched data examining the results of robotic hepatectomy using the open approach as a benchmark are still limited. We aimed to compare the clinical outcomes, survival, and costs between robotic and open hepatectomy undertaken in our tertiary hepatobiliary center. With IRB approval, we prospectively followed 285 consecutive patients undergoing hepatectomy for neoplastic liver diseases between 2012 and 2020. Propensity score matched comparison of robotic and open hepatectomy was conducted by 1:1 ratio. Data are presented as median (mean ± SD). The matching process assigned 49 patients to each arm, open and robotic hepatectomy. There were no differences in R1 resection rates (4% vs 4%; p = 1.00). Differences in perioperative variables between open and robotic hepatectomy included postoperative complications (16% vs 2%; p = 0.02) and length of stay (LOS) [6 (7 ± 5.0) vs 4 (5 ± 4.0) days; p = 0.002]. There were no differences between open and robotic hepatectomy regarding postoperative hepatic insufficiency (10% vs 2%; p = 0.20). No difference was seen in long-term survival outcomes. While there were no differences in costs, robotic hepatectomy was associated with lower reimbursement [$20,432 (39,191 ± 41,467.81) vs $33,190 (67,860 ± 87,707.81); p = 0.04] and lower contribution margin [$-11,229 (3902 ± 42,572.43) vs $8768 (34,690 ± 89,759.56); p = 0.03]. Compared to open approach, robotic hepatectomy robotic offers lower rates of postoperative complications, shorter LOS and similar costs, while not compromising long-term oncological outcomes. Robotic hepatectomy may eventually become the preferred approach in minimally invasive treatment of liver tumors.

The Effect of Body Mass Index on Patients' Outcomes Following Robotic Distal Pancreatectomy and Splenectomy.

Background and Objectives: Obesity has increased over the past decade, yet the correlation among body mass index (BMI), surgical outcomes, and the robotic platform are not well established. This study was undertaken to measure the impact of elevated BMI on outcomes after robotic distal pancreatectomy and splenectomy. Methods: We prospectively followed patients who underwent robotic distal pancreatectomy and splenectomy. Regression analysis was utilized to identify significant relationships with BMI. For illustrative purposes, the data are presented as median (mean ± SD). Significance was determined at p ≤ 0.05. Results: A total of 122 patients underwent robotic distal pancreatectomy and splenectomy. Median age was 68 (64 ± 13.3), 52% were women, and BMI was 28 (29 ± 6.1) kg/m2. One patient was underweight (< 18.5 kg/m2), 31 had normal weight (18.5-24.9 kg/m2), 43 were overweight (25-29.9 kg/m2), and 47 were obese (≥ 30 kg/m2). BMI was inversely correlated with age (p = 0.05) but there was no correlation with sex (p = 0.72). There were no statistically significant relationships between BMI and operative duration (p = 0.36), estimated blood loss (p = 0.42), intraoperative complications (p = 0.64), and conversion to open approach (p = 0.74). Major morbidity (p = 0.47), clinically relevant postoperative pancreatic fistula (p = 0.45), length of stay (p = 0.71), lymph nodes harvested (p = 0.79), tumor size (p = 0.26), and 30-day mortality (p = 0.31) were related to BMI. Conclusion: BMI has no significant effect on patients undergoing robotic distal pancreatectomy and splenectomy. BMI greater than 30 kg/m2 should not defer proceeding with robotic distal pancreatectomy with splenectomy. Limited empirical evidence exists in the literature regarding patients with a BMI greater than 30 kg/m2, and thus any proposed operative intervention should invoke sufficient planning and preparation.

Simultaneous Resection of Colorectal Carcinoma and Hepatic Metastases is Safe and Effective: Examining the Role of the Robotic Approach.

BACKGROUNDS AND OBJECTIVES: Up to 50% of patients with colorectal carcinoma (CRC) present with liver metastases (CLM) throughout their course. Complete resection of both sites provides the only chance for cure. Either a staged or simultaneous resection is feasible. The latter avoids delays in adjuvant systemic chemotherapy but may increase technical complexity and perioperative complications. We aim to evaluate our initial outcomes of simultaneous CRC and CLM resections with a focus on the robotic technique. METHOD: With institutional review board approval, we followed 26 consecutive patients who underwent simultaneous/concomitant liver and colorectal resection. Major liver resection is defined as resection of ≥3 contiguous Couinaud segments. Data are presented as median (mean ± SD). RESULTS: Patients were 64 (63 ± 14.0) years old. Body mass index was 29 (29 ± 5.7) kg/m2. 54% of patients had prior abdominal operation(s). A majority of patients were >ASA class III (73%), underwent major liver resection (62%) with robotic approach (77%). In the robotic cohort, there were no unplanned conversions to open. Estimated blood loss was 150 (210 ± 181.8) ml. Total operative duration was 446 (463 ± 93.6) minutes. Negative margins (R0) were obtained in all patients. Postoperative complication of Clavien-Dindo≥3 occurred in three patients, including one requiring reoperation with end ileostomy for anastomotic leak. Length of stay was 5 (6 ± 3.5) days. Three patients were readmitted within 30 days after discharge, none for reoperation. There was no 90-day mortality. CONCLUSION: Our cohort of concomitant CRC and CLM resection demonstrates safety and efficacy via both the open and robotic approach.

The Impact of Smoking History on Outcomes and Morbidity After Robotic Hepatectomy.

INTRODUCTION: The detrimental effects that smoking has on patient health and postoperative morbidity are well documented. However, literature on the impact that smoking history has on robotic surgery, specifically robotic hepatectomy, is scarce. This study was undertaken to determine whether smoking history impacts the postoperative course of patients undergoing robotic hepatectomy. METHODS: We prospectively followed 353 patients that underwent robotic hepatectomy. 125 patients had an apposite history of smoking (ie, smokers) and 228 patients were classified as non-smokers. Data were presented as median (mean ± SD). Patients were then propensity-score matched based on patient and tumor characteristics. RESULTS: Prior to the matching, the MELD score and cirrhosis status in patients who smoke were found to be significantly higher when compared to those who do not (mean MELD score 9 vs 8 and cirrhosis in 25% vs 13% of patients, respectively). Both smokers and non-smokers have similar BMIs, number of previous abdominal operations, ASA physical status classifications, and Child-Pugh scores. Six percent smokers vs one percent non-smokers experienced pulmonary complications (pneumonia, pneumothorax, and COPD exacerbation) (P = .02). No differences were found for postoperative complications of Clavien-Dindo score ≥ III, 30-day mortality, or 30-day readmissions. After the matching, no differences were found between the smokers and the non-smokers. CONCLUSION: After a propensity-score match analysis, smoking did not appear to negatively affect the intra- and postoperative outcomes after robotic liver resections. We believe that the robotic approach as the most modern minimally invasive technique in liver resection may have the potential to mitigate the known adverse effects of smoking.