Keeping surgeons in the loop: are handheld robotics the best path towards more autonomous actions? (A comparison of complete vs. handheld robotic hepatectomy for colorectal liver metastases)

Abstract

Aim: Some surgeons have been using some form of handheld robotics (HR) since liver resections began being done minimally invasively (MI); however, with the development of the complete robotic surgical systems (CRSS), they have lived in limbo neither being truly laparoscopic nor robotic. While doing the Study: International and Multi-centered on Minimally Invasive Liver Resections for colorectal metastases (CRLM), we decided to evaluate these two different degrees of robotics, specifically the HR group and the group undergoing a completely robotic (CR) approach.

Methods: Four international centers (one in France, one in Germany, one in Taiwan, and one in the United States of America) were asked to join a retrospective review of cases to compare short- and long-term outcomes after open, laparoscopic, and robotic liver resection for CRLMs. For this study, only patients who had either HR or CR liver resections were included. HR was defined as cases done with a robotically controlled camera holder and a powered stapling device. Only patients with ≤ 3 tumors that were ≤ 5 cm were included so that the preoperative characteristics of the two groups would be similar.

Results: In total, three centers did CR for CRLM (28 patients) and one center used HR (49 patients). MI resections were possible in 92.5% of patients when HR was used compared to 34.2% (22.6% laparoscopic, 11.5% CR) when centers used CRSS. Mean operating room times were significantly longer after CR compared to HR resections, 234 min vs. 290 min (P = 0.04). The morbidity and mortality rates were 4.1% and 2% after HR compared to 10.7% and 0% (P = NS), respectively. R0 resection rates and resection margins were 100% and 9.6 mm compared to 89.3% and 6.7 mm after HR vs. CR, respectively (P < 0.05). The estimated blood loss and length of stay were similar in both groups, 264 mL and 4.9 days vs. 227 mL and 6.8 days (P > 0.05). Overall and disease-free survival at one and two years were 100% and 89.4% after HR vs. 100% and 72.9% after CR (P > 0.05).

Conclusion: HR and CR liver resections have similar short- and long-term outcomes; however, when HR is used, over 90% of cases can be done MI compared to under 35% with CR. The added benefit of haptics and the ability for the operating surgeon to use hand assistance may account for this discrepancy. CRSS do not use haptics and surgeons must rely on visual cues; as robots become more autonomous, it may make more sense for computer engineers to work on the robot perceiving feedback and not the surgeon. HR may be the safest way to develop more autonomous actions in surgery and may yield the most benefits for patients by keeping the surgeon in the loop.

Keywords

Minimally invasive surgery / laparoscopy / liver resection / hepatectomy / robotic-assisted surgery / hepatic surgery / hepatobiliary / handheld robotics / complete surgical robotic system

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