ROBOTIC LIVER RESECTION. REPORT OF THE FIRST 50 CASES.

BACKGROUND: Robotic surgery has gained growing acceptance in recent years, expanding to liver resection. OBJECTIVE: The aim of this paper is to report the experience with our first fifty robotic liver resections. METHODS: This was a single-cohort, retrospective study. From May 2018 to December 2020, 50 consecutive patients underwent robotic liver resection in a single center. All patients with indication for minimally invasive liver resection underwent robotic hepatectomy. The indication for the use of minimally invasive technique followed practical guidelines based on the second international laparoscopic liver consensus conference. RESULTS: The proportion of robotic liver resection was 58.8% of all liver resections. Thirty women and 20 men with median age of 61 years underwent robotic liver resection. Forty-two patients were operated on for malignant diseases. Major liver resection was performed in 16 (32%) patients. Intrahepatic Glissonian approach was used in 28 patients for anatomical resection. In sixteen patients, the robotic liver resection was a redo hepatectomy. In 10 patients, previous liver resection was an open resection and in six it was minimally invasive resection. Simultaneous colon resection was done in three patients. One patient was converted to open resection. Two patients received blood transfusion. Four (8%) patients presented postoperative complications. No 90-day mortality was observed. CONCLUSION: The use of the robot for liver surgery allowed to perform increasingly difficult procedures with similar outcomes of less difficult liver resections.

Hepatectomia robótica. Relato dos primeiros 50 casos / Robotic liver resection. report of the first 50 cases

ABSTRACT BACKGROUND: Robotic surgery has gained growing acceptance in recent years, expanding to liver resection. OBJECTIVE: The aim of this paper is to report the experience with our first fifty robotic liver resections. METHODS: This was a single-cohort, retrospective study. From May 2018 to December 2020, 50 consecutive patients underwent robotic liver resection in a single center. All patients with indication for minimally invasive liver resection underwent robotic hepatectomy. The indication for the use of minimally invasive technique followed practical guidelines based on the second international laparoscopic liver consensus conference. RESULTS: The proportion of robotic liver resection was 58.8% of all liver resections. Thirty women and 20 men with median age of 61 years underwent robotic liver resection. Forty-two patients were operated on for malignant diseases. Major liver resection was performed in 16 (32%) patients. Intrahepatic Glissonian approach was used in 28 patients for anatomical resection. In sixteen patients, the robotic liver resection was a redo hepatectomy. In 10 patients, previous liver resection was an open resection and in six it was minimally invasive resection. Simultaneous colon resection was done in three patients. One patient was converted to open resection. Two patients received blood transfusion. Four (8%) patients presented postoperative complications. No 90-day mortality was observed. CONCLUSION: The use of the robot for liver surgery allowed to perform increasingly difficult procedures with similar outcomes of less difficult liver resections.

RESUMO CONTEXTO: A cirurgia robótica tem tido aceitação crescente nos últimos anos, expandindo-se para a ressecção hepática. OBJETIVO: Relatar a experiência com as primeiras cinquenta ressecções hepáticas robóticas. MÉTODOS: Trata-se de análise retrospectiva de dados coletados prospectivamente. De maio de 2018 a dezembro de 2020, 50 pacientes consecutivos foram submetidos à ressecção hepática robótica em um único centro. Todos os pacientes com indicação de ressecção hepática minimamente invasiva foram submetidos à hepatectomia robótica. A indicação de técnica minimamente invasiva seguiu as diretrizes práticas baseadas na segunda conferência internacional de consenso laparoscópico hepático. RESULTADOS: A proporção de ressecções hepáticas robóticas foi de 58,8% de todas as ressecções hepáticas. Trinta mulheres e 20 homens com idade mediana de 61 anos foram submetidos à ressecção hepática robótica. Quarenta e dois pacientes foram operados por doenças malignas. Ressecção hepática maior foi realizada em 16 (32%) pacientes. A abordagem Glissoniana intra-hepática foi usada em 28 pacientes para ressecção anatômica. Em 16 pacientes, a ressecção hepática robótica foi uma re-hepatectomia. Em 10, a hepatectomia prévia foi aberta e em seis foi por via minimamente invasiva. Ressecção simultânea do cólon foi feita em três pacientes. Um paciente foi convertido para ressecção aberta. Dois pacientes receberam transfusão sanguínea. Quatro (8%) pacientes apresentaram complicações pós-operatórias. Mortalidade em 90 dias foi nula. CONCLUSÃO: O uso do robô permitiu realizar procedimentos progressivamente mais complexos com resultados semelhantes às hepatectomias menos complexas.

Robotic Resection and Reconstruction of the Superior Mesenteric Vein Without Graft During Pancreatoduodenectomy (with Video).

BACKGROUND: Pancreatoduodenectomy is the procedure of choice for tumors in the head of the pancreas. Invasion of major vessels is a relative contraindication for minimally invasive approach. We present a video of a robotic resection and reconstruction of the superior mesenteric vein (SMV) without the use of a graft during pancreatoduodenectomy. METHODS: A 56-year-old female with ductal adenocarcinoma is referred for treatment. CT scan and endoscopic ultrasound showed a 3-cm tumor in the pancreatic head with contact with SMV. The multidisciplinary team decided for upfront surgery. Robotic superior mesenteric artery first approach was used to release the head of the pancreas, so the whole surgical specimen is only attached by the tumor invasion of the SM. After the partial resection of the SMV, its extension precluded lateral suture and a transverse anastomosis was necessary to minimize the risk of narrowing of the SMV. After completion of the venous anastomosis, reconstruction of the alimentary tract was done as usual. RESULTS: Operative time was 430 min. Time of clamping was 30 min and the time for the SMV suture is 23 min. Estimated blood loss was 370 mL. Pathology confirmed a T3N1 ductal adenocarcinoma with free margins. The patient was discharged on the 7th postoperative day. CONCLUSIONS: Robotic resection and reconstruction of the SMV is safe and feasible without graft during pancreatoduodenectomy in patients with invasion but not encasing of the portal vein or SMV. The proposed technique should be used in cases where the invasion requires extended resection that precludes simple lateral suture.

Robotic Right Hepatectomy with Portal Vein Thrombectomy for Colorectal Liver Metastasis (with Video).

BACKGROUND: Hepatectomy is the standard treatment for colorectal liver metastases. However, the high recurrence rate is a persistent problem that occurs in up to 65% of patients. Repeat hepatectomy is a feasible treatment and may offer favorable surviva but is technically demanding so minimally invasive repeat hepatectomy has been used in a few patients. Colorectal liver metastases are different from hepatocellular carcinoma and rarely present with macroscopic portal vein tumoral thrombus. To the best of our knowledge, minimally invasive approaches for this rare condition have not yet been reported. METHOD: We present here a video of a robotic right hepatectomy in a patient with single colorectal liver metastasis and macroscopic tumor thrombi in the right portal vein. A 61-year-old woman underwent open resection of a transverse colon cancer (T3N0M0) in December 2015. In March 2019, she underwent nonanatomical resection of a liver metastases located in segment 6 also via an open approach. She then underwent adjuvant chemotherapy. However, in September 2020, she presented with a local recurrence and a tumor thrombus in the right portal vein. She was then referred to us for treatment and a multidisciplinary team decided on upfront liver resection due to the risk of left portal vein progression. Liver volumetry showed future liver remnant of 52.5%. Right hepatectomy with portal vein thrombectomy was indicated. A robotic approach was proposed, and consent was obtained. RESULTS: The Da Vinci system was used. The operation began with the division of adhesions from previous laparotomies. Intraoperative ultrasound was performed to locate the tumor and to confirm the portal vein invasion. Hepatic hilum was carefully dissected. The replaced right hepatic artery from the superior mesenteric artery was ligated and divided. The common bile duct was dissected and encircled with a vessel loop. The portal vein was dissected, and an enlarged right portal vein with a protruding tumoral thrombus was seen. The left portal vein and portal vein trunk were then temporarily clamped. The right portal vein was carefully transected with robotic scissors being careful not to displace the thrombus. A minimum stump was left to safely suture the portal vein. The portal vein was then closed with a running 5-0 prolene suture. The portal vein clamping was then released, and a patent anastomosis with no leakage was observed. Right liver ischemic discoloration was seen and confirmed with fluorescence imaging after indocyanine green injection. A future line of transection was marked along ischemic area. The liver was divided using bipolar forceps under saline irrigation until it was detached from the retrohepatic vena cava. A right hepatic vein was divided with a stapler to complete the right hepatectomy. The surgical specimen was removed through a suprapubic incision, and the abdominal cavity was drained with a closed-suction drain. The total operative time was 270 min with no transfusion. Pathology conformed the diagnosis with free surgical margins. CONCLUSION: Robotic right hepatectomy with tumor thrombectomy is feasible and safe even in the presence of lobar portal vein invasion. This video may help HPB surgeons perform this complex procedure.

Robotic Resection of Postero-Superior Liver Segments (7,8) (with Video).

BACKGROUND: Surgical resection is the standard treatment for colorectal liver metastases. Parenchyma-sparing technique should always be attemptedto prevent postoperative liver failure and increase the opportunity to perform repeated resections in cases of recurrent malignancy. Postero-superior liverresection is defined as the anatomical removal of liver segments 7 and 8, however, minimally invasive resection of postero-superior liver segments isconsidered a difficult and complex operation and thus is rarely reported. METHODS: We present the video of a robotic postero-superior liver resection in a 54-year-old male patient with a synchronous, single, and large colorectal metastasis in the postero-superior liver sector. The Da Vinci Xi system was used. The right liver was mobilized with exposure of the inferior vena cava (IVC), following by intraoperative ultrasound, used to locate the tumor and establish its relationship to the right hepatic vein and portal pedicles fromsegments 7 and 8. A thick hepatic vein draining directly to the IVC was controlled with hem-o-lock and the right hepatic vein was divided using anendoscopic stapler. The surgical specimen was removed through a supra-pubic incision. RESULTS: Operative time was 205 minutes, and the estimated blood loss was 310 mL. The patient's recovery was uneventful with no need for admission tothe intensive care unit or for blood transfusion. Pathology confirmed colorectal metastasis with free surgical margins. CONCLUSIONS: Robotic resection of postero-superior liver segments is feasible and safe and may have some advantages over laparoscopic and openapproaches. This video may help gastrointestinal surgeons perform this complex procedure.

Robotic pancreatic resection. Personal experience with 105 cases.

OBJECTIVE: the first robotic pancreatic resection in Brazil was performed by our team in 2008. Since March 2018, a new policy prompted us to systematically employ the robot in all minimally invasive pancreatic surgery. The aim of this paper is to review our experience with robotic pancreatic resection. METHODS: all patients who underwent robotic pancreatic resection from March 2018 through December 2019 were identified. Descriptive data were collected. Preoperative variables included age, sex, and indication for surgery. Intraoperative variables included operative time, bleeding, blood transfusion. RESULTS: 105 patients underwent robotic pancreatectomy. Median age was 60.5 years old. Fifty-five patients were female. 51 patients underwent robotic pancreatoduodenectomies, 34 distal pancreatectomy. Morbidity was 23.8%, mainly related to postoperative pancreatic fistula and one death occurred (mortality of 0.9%). Three patients (2.8%) were converted to open surgery. Four patients had delayed gastric emptying and two presented bleeding. Twenty-four patients had pancreatic fistula that was treated conservatively with late removal of the pancreatic drain. No patient required percutaneous drainage, reintervention or hospital readmission. CONCLUSIONS: the robotic platform is useful for the reconstruction of the alimentary tract after pancreatoduodenectomy or after central pancreatectomy. It may increase the preservation of the spleen during distal pancreatectomies. Pancreas sparing techniques, such as enucleation, resection of uncinate process and central pancreatectomy, should be used to avoid exocrine and/or endocrine insufficiency. Robotic resection of the pancreas is safe and feasible for selected patients. It should be performed in specialized centers by surgeons with experience in both open and minimally invasive pancreatic surgery.

Robotic pancreatic resection. Personal experience with 105 cases / Ressecção pancreática robótica. Experiência pessoal com 105 casos

ABSTRACT Objective: the first robotic pancreatic resection in Brazil was performed by our team in 2008. Since March 2018, a new policy prompted us to systematically employ the robot in all minimally invasive pancreatic surgery. The aim of this paper is to review our experience with robotic pancreatic resection. Methods: all patients who underwent robotic pancreatic resection from March 2018 through December 2019 were identified. Descriptive data were collected. Preoperative variables included age, sex, and indication for surgery. Intraoperative variables included operative time, bleeding, blood transfusion. Results: 105 patients underwent robotic pancreatectomy. Median age was 60.5 years old. Fifty-five patients were female. 51 patients underwent robotic pancreatoduodenectomies, 34 distal pancreatectomy. Morbidity was 23.8%, mainly related to postoperative pancreatic fistula and one death occurred (mortality of 0.9%). Three patients (2.8%) were converted to open surgery. Four patients had delayed gastric emptying and two presented bleeding. Twenty-four patients had pancreatic fistula that was treated conservatively with late removal of the pancreatic drain. No patient required percutaneous drainage, reintervention or hospital readmission. Conclusions: the robotic platform is useful for the reconstruction of the alimentary tract after pancreatoduodenectomy or after central pancreatectomy. It may increase the preservation of the spleen during distal pancreatectomies. Pancreas sparing techniques, such as enucleation, resection of uncinate process and central pancreatectomy, should be used to avoid exocrine and/or endocrine insufficiency. Robotic resection of the pancreas is safe and feasible for selected patients. It should be performed in specialized centers by surgeons with experience in both open and minimally invasive pancreatic surgery.

RESUMO Objetivo: a primeira ressecção pancreática robótica no Brasil foi realizada por nossa equipe em 2008. Desde março de 2018, uma nova política nos levou a empregar sistematicamente o robô em todas cirurgias pancreáticas minimamente invasivas. O objetivo deste artigo é revisar nossa experiência com a ressecção pancreática robótica. Métodos: todos os pacientes submetidos a ressecção pancreática robótica de 2018 a 2019 foram incluídos. Variáveis pré- e intraoperatórias como idade, sexo, indicação, tempo cirúrgico, sangramento, diagnóstico, tamanho do tumor foram analisados. Resultados: 105 pacientes foram submetidos a pancreatectomia robótica. A idade mediana dos pacientes foi de 60,5 anos. 55 pacientes eram do sexo feminino. 51 pacientes foram submetidos a pancreatoduodenectomia, 34 pancreatectomia distal. A morbidade foi de 23,8% e ocorreu um óbito (mortalidade de 0,9%). Três pacientes (2,8%) tiveram a operação convertida para aberta. Quatro pacientes apresentaram retardo no esvaziamento gástrico e dois apresentaram sangramento. Vinte e quatro pacientes apresentaram fístula pancreática tratada de forma conservadora com remoção tardia do dreno pancreático. Nenhum paciente necessitou de drenagem percutânea, reintervenção ou readmissão hospitalar. Conclusões: a plataforma robótica é útil para a reconstrução do trato alimentar após pancreatoduodenectomia ou após pancreatectomia central. Pode aumentar a preservação do baço durante pancreatectomias distais. Técnicas poupadoras de pâncreas, como enucleação, ressecção de processo uncinado e pancreatectomia central, devem ser usadas para evitar insuficiência exócrina e/ou endócrina. A ressecção robótica do pâncreas é segura e viável para pacientes selecionados. Deve ser realizada em centros especializados por cirurgiões com experiência em cirurgia pancreática aberta e minimamente invasiva.