Strategies to build a robotic liver surgery program

Abstract

Over the past few decades, an increasing proportion of abdominal surgeries are performed through minimally invasive platforms. In contrast, adaptation of minimally invasive techniques for liver surgery has garnered slower attraction due to the complexity and associated morbidity and mortality with these operations. Compared to laparoscopy, the robotic-assisted surgical system provides a three-dimensional operative view and instruments with articulation that mimic and extend wrist movement. These elements improve operative dexterity making dissection and suturing easier. Additionally, robotic surgery improves operative ergonomics and decreases physical and mental fatigue. Studies show that the robotic platform is safe and versatile with many technical advantages for complex operations, improved short-term outcomes compared to open surgery, and comparable oncologic outcomes. As such, hepatobiliary surgeons are increasingly adapting robotic techniques in their practice. It is crucial that as more hospitals adopt this technology, patient safety monitoring and quality initiatives are maintained. Establishing a robotic liver surgery program revolves around three pillars: designing a curriculum to overcome the learning curve, building a strong clinical and administrative team, and appropriate patient selection.

Keywords

Robotic surgery / liver surgery / curriculum / learning curve

References

[1] Gagner M,Selzer D.Laparoscopic liver resection: benefits and controversies.Surg Clin North Am2004;84:451-62

[2] He J,Spolverato G.National trends with a laparoscopic liver resection: results from a population-based analysis.HPB2015;17:919-26 PMCID:PMC4571760

[3] Ciria R,Geller DA,Wakabayashi G.Comparative short-term benefits of laparoscopic liver resection: 9000 cases and climbing.Ann Surg2016;263:761-77

[4] Jin B,Fei YT,Mao YL.Safety and efficacy for laparoscopic versus open hepatectomy: a meta-analysis.Surg Oncol2018;27:A26-34

[5] Aghayan DL, Kazaryan AM, Dagenborg VJ, et al; OSLO-COMET Survival Study Collaborators. Long-term oncologic outcomes after laparoscopic versus open resection for colorectal liver metastases : a randomized trial. Ann Intern Med 2021;174:175-82.

[6] He Y,Liang T.Laparoscopic versus open hepatectomy for hepatocellular carcinoma with cirrhosis: a single-center propensity score matching analysis.Ann Transl Med2021;9:1733 PMCID:PMC8743702

[7] Takahara T,Beppu T.Long-term and perioperative outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with propensity score matching: a multi-institutional Japanese study.J Hepatobiliary Pancreat Sci2015;22:721-7

[8] Kabir T,Syn NL.Laparoscopic versus open resection of hepatocellular carcinoma in patients with cirrhosis: meta-analysis.Br J Surg2021;109:21-9

[9] Fay K.Should robot-assisted surgery tolerate or even accommodate less surgical dexterity?.AMA J Ethics2023;25:E609-614

[10] Liang B,Yang W.Robotic versus laparoscopic liver resection for posterosuperior segments: a systematic review and meta-analysis.HPB2024;In press:

[11] Sijberden JP, Hoogteijling TJ, Aghayan D, et al; International consortium on Minimally Invasive Liver Surgery (I-MILS). Robotic versus laparoscopic liver resection in various settings: an international multicenter propensity score matched study of 10.075 patients. Ann Surg 2024;280:108-17. PMCID:PMC11161239

[12] Winckelmans T,Parmentier I,Verslype C.Robotic versus laparoscopic hepatectomy: a single surgeon experience of 629 consecutive minimally invasive liver resections.World J Surg2023;47:2241-9

[13] Fruscione M,Baker EH.Robotic-assisted versus laparoscopic major liver resection: analysis of outcomes from a single center.HPB2019;21:906-11

[14] Tsung A,Sukato DC.Robotic versus laparoscopic hepatectomy: a matched comparison.Ann Surg2014;259:549-55

[15] Chiow AKH, Fuks D, Choi GH, et al; International Robotic and Laparoscopic Liver Resection Study Group collaborators. International multicentre propensity score-matched analysis comparing robotic versus laparoscopic right posterior sectionectomy. Br J Surg 2021;108:1513-20. PMCID:PMC8743054

[16] Fagenson AM,Pitt HA.Minimally invasive hepatectomy in North America: laparoscopic versus robotic.J Gastrointest Surg2021;25:85-93

[17] Chong Y, Prieto M, Gastaca M, et al; International robotic and laparoscopic liver resection study group investigators. An international multicentre propensity score matched analysis comparing between robotic versus laparoscopic left lateral sectionectomy. Surg Endosc 2023;37:3439-48. PMCID:PMC10164043

[18] Vining CC,Kuchta K.Risk factors and outcomes in patients undergoing minimally invasive hepatectomy with unplanned conversion: a contemporary NSQIP analysis.HPB2023;25:577-88

[19] Kamel MK,Keane CA.National trends and perioperative outcomes of robotic-assisted hepatectomy in the USA: a propensity-score matched analysis from the national cancer database.World J Surg2022;46:189-96

[20] Zhu P,Ding ZY.Learning curve in robot-assisted laparoscopic liver resection.J Gastrointest Surg2019;23:1778-87

[21] Fukumori D,Penninga L,Svendsen LB.Learning curves in robot-assisted minimally invasive liver surgery at a high-volume center in Denmark: report of the first 100 patients and review of literature.Scand J Surg2023;112:164-72

[22] Krenzien F,Feldbrügge L.Complexity-adjusted learning curves for robotic and laparoscopic liver resection: a word of caution.Ann Surg Open2022;3:e131 PMCID:PMC10431481

[23] Boone BA,Hogg ME.Assessment of quality outcomes for robotic pancreaticoduodenectomy: identification of the learning curve.JAMA Surg2015;150:416-22

[24] Mark Knab L,Khodakov A.Evolution of a novel robotic training curriculum in a complex general surgical oncology fellowship.Ann Surg Oncol2018;25:3445-52

[25] Abbas AI, Jung JP, Rice MK, Zureikat AH, Zeh HJ 3rd, Hogg ME. Methodology for developing an educational and research video library in minimally invasive surgery.J Surg Educ2019;76:745-55

[26] Rice MK,Novak SM.Crowdsourced assessment of inanimate biotissue drills: a valid and cost-effective way to evaluate surgical trainees.J Surg Educ2019;76:814-23

[27] Tam V,Novak S.Robotic pancreatoduodenectomy biotissue curriculum has validity and improves technical performance for surgical oncology fellows.J Surg Educ2017;74:1057-65

[28] Hogg ME,Zenati M.Mastery-based virtual reality robotic simulation curriculum: the first step toward operative robotic proficiency.J Surg Educ2017;74:477-85

[29] Rice MK,Bellon J.Association of mentorship and a formal robotic proficiency skills curriculum with subsequent generations’ learning curve and safety for robotic pancreaticoduodenectomy.JAMA Surg2020;155:607-15 PMCID:PMC7240650

[30] Nota CL,Hagendoorn J.Setting up a robotic hepatectomy program: a Western-European experience and perspective.Hepatobiliary Surg Nutr2017;6:239-45 PMCID:PMC5554759

[31] Lai ECH.Training robotic hepatectomy: the Hong Kong experience and perspective.Hepatobiliary Surg Nutr2017;6:222-9 PMCID:PMC5554762

[32] King JC,Zureikat AH.Safety in numbers: progressive implementation of a robotics program in an academic surgical oncology practice.Surg Innov2016;23:407-14

[33] Wu CY,Chou WH,Huang CS.Is robotic hepatectomy cost-effective? In view of patient-reported outcomes.Asian J Surg2019;42:543-50

[34] Cortolillo N,Parreco J,Castillo A.Nationwide outcomes and costs of laparoscopic and robotic vs. open hepatectomy.J Robot Surg2019;13:557-65

[35] Shapera E,Syblis C.Cost analysis of robotic versus open hepatectomy: is the robotic platform more expensive?.J Robot Surg2022;16:1409-17

[36] Grimsley EA,Janjua H,DuCoin C.Exploring the paradigm of robotic surgery and its contribution to the growth of surgical volume.Surg Open Sci2022;10:36-42 PMCID:PMC9307663

[37] Luberice K,Modasi A.Applying IWATE criteria to robotic hepatectomy: is there a “robotic effect”?.HPB2021;23:899-906