**6. Future outlook**

While limitations within robotic hepatic surgery exist, the future outlook for incorporation of robotics into liver surgery, with additional integration of other technology offers exciting promise.

Robotics systems, with the primary operator working from a non-sterile station with a visual screen, already offers the opportunity to consult pre-operative imaging for comparison to intra operative findings. Infrared fluorescence technology, incorporated into robotics systems, offers visualisation of vital biliary and vascular structures with near fluorescence of indocyanin green. This poses a major advantage during dissection of the liver hilar structures, where anatomical variation is commonplace and iatrogenic injury can prove catastrophic. With constantly improving imaging and artificial intelligence technology, it is not difficult to imagine intraoperative overlay of imaging to on screen anatomical structures allowing real-time surgical decision making, such as lymph node dissection or surgical resection margins. With the rise of artificial intelligence integrated into robotic systems, it is possible that pre-operative structural recognition of vital hepatobiliary

**21**

**Author details**

**7. Conclusion**

United Kingdom

Mushfique Alam, Robert Young and Rafael Diaz-Nieto\*

provided the original work is properly cited.

innovation and research for robotic liver surgery.

Hepatobiliary Surgery Unit, Liverpool University Hospital, Liverpool,

\*Address all correspondence to: rafael.diaz-nieto@liverpoolft.nhs.uk

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Robotic Liver Surgery*

supervisory role.

*DOI: http://dx.doi.org/10.5772/intechopen.99123*

basis will be essential for surgical training.

structures or predefined areas within resection margins could be predefined as "no go areas" during operative intervention offering intraoperative artificial intelligence guidance to the operating surgeon. It is perhaps even conceivable that automated robots could perform hepatic resections, with the primary surgeon adopting a

While questions are understandably raised regarding the early stages of surgical training on robotic systems, telecommunications incorporated into robotic systems can arguably vastly improve training in the latter stages. With shared access, real time intra-operative images could be viewed on technology outside of the operating theatres allowing recommendations from experienced colleagues in the event of intraoperative uncertainty. Indeed, it is conceivable the operative control could be

Perhaps the most important aspect of the future of robotic surgery, however, will be widespread inclusion into standard surgical practice. If robotic surgery is to exist outside of a few specialist centres, a balance must be struck between using robotics for the most complex technical cases, where a clear evidence base exists within the literature, and the everyday use of the robotic system, allowing not only the operating surgeon but also whole team to become at home managing and trouble-shooting issues that arise with all technology. While major advantages of routine use of robotic technology for, for example, minimally invasive cholecystectomy will be difficult to evidence, adoption of such technology on a day-to-day

Robotic liver surgery is rapidly evolving. There is growing evidence suggesting this approach to be feasible and safe. This evidence however is limited to highly specialised centres and cannot be consider standard of care. Robotic liver surgery shares the advantages of laparoscopic liver surgery and both should be developed in parallel to promote wider access to minimally invasive surgery for patients undergoing liver resections. Certain limitations remain whilst there is a promising future of

managed at work-stations distant to the immediate operating theatre.

## *Robotic Liver Surgery DOI: http://dx.doi.org/10.5772/intechopen.99123*

*Latest Developments in Medical Robotics Systems*

open surgery [50, 51].

literature to avoid publication bias.

forces. While much comment was made on this in the advent of laparoscopic surgery, the degree of tactile feedback offered in early robotic surgery systems was even less. Hydraulic haptic feedback systems are, however, already in development with in vivo trials showing significant grip strength reduction more akin to that in

As with any novel surgical technology, it is necessary to temper adoption of technology with strict clinical governance to maximise patient safety. This includes inclusion of robotics cases in morbidity and mortality discussions, a forum for discussing serious untoward events and near misses, and strategies within scientific

Obesity has become an epidemic in many parts of the western world and extremes of BMI offer difficulties in many aspects of surgical practice. While a number of studies in other surgical subspecialties have shown the robotic approach not to offer significantly worsened outcomes in extremes of BMI, hepatobiliary surgery offers specific challenges with non alcoholic fatty liver disease, steatohepa-

A recently published US study examined the effects of BMI, prospectively observing outcomes in patient subgroups of BMIs <25, 25-35 and > 35, found no significant differences found in operative blood loss, operative time of length of stay [55]. With a relatively small number of patients in this study however, more work is required to accurately identify the possible difficulties or benefits posed

Operative training is a vital part of any health service in order to provide future

While limitations within robotic hepatic surgery exist, the future outlook for incorporation of robotics into liver surgery, with additional integration of other

Robotics systems, with the primary operator working from a non-sterile station with a visual screen, already offers the opportunity to consult pre-operative imaging for comparison to intra operative findings. Infrared fluorescence technology, incorporated into robotics systems, offers visualisation of vital biliary and vascular structures with near fluorescence of indocyanin green. This poses a major advantage during dissection of the liver hilar structures, where anatomical variation is commonplace and iatrogenic injury can prove catastrophic. With constantly improving imaging and artificial intelligence technology, it is not difficult to imagine intraoperative overlay of imaging to on screen anatomical structures allowing real-time surgical decision making, such as lymph node dissection or surgical resection margins. With the rise of artificial intelligence integrated into robotic systems, it is possible that pre-operative structural recognition of vital hepatobiliary

surgeons adequate experience and competence to take on standard as well as challenging cases with a minimal access approach. While early adopters of robotic surgery are often consultant surgeons with strong minimal access laparoscopic practice, for these enthusiasts to become robotic trainers themselves takes time for building of robotic experience. It is therefore expected that robotic training for surgeons in formal training stages will take time to diffuse down, as with the uptake of any new surgical practice. However, flatter learning curves with robotic surgery, with dual operator consoles and built-in simulation trainer modules to robotic surgical systems can offer clinical and non-clinical based training experience. These opportunities will increase with a corresponding increasing prevalence of robotic

titis and liver cirrhosis associated with morbid obesity [52–54].

with hepatic robotic surgery in the obese patient cohort.

systems within healthcare institutions.

technology offers exciting promise.

**6. Future outlook**

**20**

structures or predefined areas within resection margins could be predefined as "no go areas" during operative intervention offering intraoperative artificial intelligence guidance to the operating surgeon. It is perhaps even conceivable that automated robots could perform hepatic resections, with the primary surgeon adopting a supervisory role.

While questions are understandably raised regarding the early stages of surgical training on robotic systems, telecommunications incorporated into robotic systems can arguably vastly improve training in the latter stages. With shared access, real time intra-operative images could be viewed on technology outside of the operating theatres allowing recommendations from experienced colleagues in the event of intraoperative uncertainty. Indeed, it is conceivable the operative control could be managed at work-stations distant to the immediate operating theatre.

Perhaps the most important aspect of the future of robotic surgery, however, will be widespread inclusion into standard surgical practice. If robotic surgery is to exist outside of a few specialist centres, a balance must be struck between using robotics for the most complex technical cases, where a clear evidence base exists within the literature, and the everyday use of the robotic system, allowing not only the operating surgeon but also whole team to become at home managing and trouble-shooting issues that arise with all technology. While major advantages of routine use of robotic technology for, for example, minimally invasive cholecystectomy will be difficult to evidence, adoption of such technology on a day-to-day basis will be essential for surgical training.
