**5. Limitations**

As with other subspecialties of surgery, while the robotic approach can confer major operative advantages, limitations also exist and it is important to consider these closely, not only for assessment of robotic feasibility, but also in order to adopt adoptions of solutions to such limitations.

The initial purchase of robotic systems poses a major financial outlay to healthcare institutions. With many health systems facing unprecedented pressures, such upfront costs may be difficult to meet. Ongoing maintenance and updates to newer

**19**

*Robotic Liver Surgery*

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

ing newer market technology.

growing surgical evidence base will add to financial expense.

become common place in the operating theatre complex.

confer an overall institutional financial advantage.

increased case load for theatre lists.

robotic models, as well as requirement for further robotic systems associated with a

Such upfront costs may make the financial case for initial investments difficult in a publicly funded health care system such at the UK National Health Service. However, as with all technology, costs of equipment have already been seen to decrease in older models, while newer designs remain at the top of the market. In the same way that laparoscopic stacks and equipment, initially considered a major investment, are now considered as standard in any theatres inventory (albeit with differing quality across healthcare institutions) robotic theatre systems are likely to

Furthermore, while the earliest days of robotic surgery, saw one company at the forefront of robotic design and technology, maintain a virtual monopoly on the robotic equipment, market competitors have already emerged, a trend which looks set to continue. This is highly likely to bring about a reduction in costs. In this context however, it cannot be assumed that an evidence base for robotic surgery built on one robotic system is necessarily transferable to different systems, and care must be taken when applying this evidence and making financial decisions regard-

In a manner not dissimilar to the initial uptake of laparoscopic minimally invasive surgery in the twentieth century, the uptake of robotic surgery within hepatobiliary surgery has not been as marked as within other surgical specialties. However, this may confer an advantage in financial terms, where robots already purchased and present in theatres based on an early uptake in other specialties can be utilised

Another disadvantage posed in much of the literature, in both major and minor liver resections is increased operative time, although the clinical maxim "surgical time in measured in inpatient days, not theatre minutes" may be prescient here. Whilst theatre time is a precious financial resource, particularly in an era of unprecedented surgical waiting lists, reduced critical care and overall inpatient stays could

Length of surgical theatre time is multifactorial. Technical learning curves of individual surgeons, which have previously shown to be flatter than that of laparoscopic surgery, show operating times inversely proportion to training and experience, as expected with any new skill set [49]. Furthermore, overall operating theatre time not only encompasses the primary surgical procedure, but also robotic system set up, patient positioning, robot docking, and additional tasks performed by the theatre team as a whole. In a similar fashion to the primary surgeon activity discussed above, the increased experience of adequately trained and well drilled theatre team can be expected to significantly reduced theatre times, allowing an

While every surgical speciality performs unique technical tasks requiring specific equipment, liver surgery, to perhaps a greater extent than other forms of abdominal surgery, utilise a cornucopia of specific tools not common to other subspecialties. Ultrasonic probes, used for intra operative identification of specific lesion, hepatobiliary specific energy devices and minimally invasive articulated retractors, as well as ultrasonic surgical aspirators, which allow cavitation and aspiration of hepatocytes whilst sparing vascular and biliary structures, are not yet incorporated into standard robotic systems. This technology, however, already exists within the minimal access domain of laparoscopic surgery, so incorporation

An often described limitation of MIS is the relative lack of tactile feedback present in open surgery, making dissection of difficult but vital structures significantly more challenging, with potential for catastrophic tissue damage from excessive

into robotic systems should not pose an insurmountable barrier.

for education and training in less robotically advanced surgical specialities.

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

*Latest Developments in Medical Robotics Systems*

rate at 42% and 65% respectively [5].

**4.3 Cholangiocarcinoma (CAA)**

equivalence of robotic MIS for CCA.

adoptions of solutions to such limitations.

**4.4 Gallbladder Cancer**

**5. Limitations**

awaited.

**4.2 Colorectal liver metastases (CRLM)**

72% (Chen et al). The overall 3 year survival rate was approximately 98% and 93% [36, 37]. The remaining study compared the oncological outcomes between robotic and laparoscopic resections and reported the 5 year disease free and overall survival

Seven studies have examined the oncological outcomes from robotic hepatectomy for colorectal liver metastases. A 100% R0 resection rate was reported by 5 of the 7, whilst the remaining 2 studies reported a rate of 92% and 73.7% [23, 38–43]. A single study evaluated longer term oncological outcomes, and in a propensity matched comparison to laparoscopic resections, reported equivalent 5 year disease free and overall survival rates at 38% and 61% respectively [43]. Matched comparisons of long term oncological outcomes between open and robotic surgery are

Minimally Invasive Surgery utilising a robotic approach should theoretically convey the significant advantages to hilar CCA resections given the necessity of extreme precision and micro-anastomosis formation. However CCA resections form less than 10% of robotic liver surgery in the current literature, likely due to the required tertiary level of surgical expertise and robotic technology [22]. As such, the literature exploring oncolocological outcomes is very limited. The largest case series (48 patients) of patients undergoing robotic resections for Type I, II and III CCA, reported successful lymphadenectomy from stations 7,8,9, 12 and 13 and an R0 resection rate of 72.9% [44]. A single study has reported on longer term outcomes following robotic resections and demonstrated significantly higher rates of recurrence and peritoneal disease when compared to a contemporaneous group of open resections in the same centre [45]. As such whilst technically feasible and safe in expert hands, further studies are required to fully elucidate the oncological

When compared to open radical cholecystectomy, the robotic approach has been shown to result in analogous operative times, blood loss, and length of stay. Specialist centres have also reported equivalent lymph node yields and demonstrated the feasibility of complete robotic lymphadenectomy of stations 8,9 12 and 13 [46–48]. An 100% R0 resection rate has been reported by the only 2 studies that present oncological outcomes [47, 48]. To date, no studies have yet to report on

As with other subspecialties of surgery, while the robotic approach can confer major operative advantages, limitations also exist and it is important to consider these closely, not only for assessment of robotic feasibility, but also in order to adopt

The initial purchase of robotic systems poses a major financial outlay to healthcare institutions. With many health systems facing unprecedented pressures, such upfront costs may be difficult to meet. Ongoing maintenance and updates to newer

longer term oncological data following robotic radical cholecystectomy.

**18**

robotic models, as well as requirement for further robotic systems associated with a growing surgical evidence base will add to financial expense.

Such upfront costs may make the financial case for initial investments difficult in a publicly funded health care system such at the UK National Health Service. However, as with all technology, costs of equipment have already been seen to decrease in older models, while newer designs remain at the top of the market. In the same way that laparoscopic stacks and equipment, initially considered a major investment, are now considered as standard in any theatres inventory (albeit with differing quality across healthcare institutions) robotic theatre systems are likely to become common place in the operating theatre complex.

Furthermore, while the earliest days of robotic surgery, saw one company at the forefront of robotic design and technology, maintain a virtual monopoly on the robotic equipment, market competitors have already emerged, a trend which looks set to continue. This is highly likely to bring about a reduction in costs. In this context however, it cannot be assumed that an evidence base for robotic surgery built on one robotic system is necessarily transferable to different systems, and care must be taken when applying this evidence and making financial decisions regarding newer market technology.

In a manner not dissimilar to the initial uptake of laparoscopic minimally invasive surgery in the twentieth century, the uptake of robotic surgery within hepatobiliary surgery has not been as marked as within other surgical specialties. However, this may confer an advantage in financial terms, where robots already purchased and present in theatres based on an early uptake in other specialties can be utilised for education and training in less robotically advanced surgical specialities.

Another disadvantage posed in much of the literature, in both major and minor liver resections is increased operative time, although the clinical maxim "surgical time in measured in inpatient days, not theatre minutes" may be prescient here. Whilst theatre time is a precious financial resource, particularly in an era of unprecedented surgical waiting lists, reduced critical care and overall inpatient stays could confer an overall institutional financial advantage.

Length of surgical theatre time is multifactorial. Technical learning curves of individual surgeons, which have previously shown to be flatter than that of laparoscopic surgery, show operating times inversely proportion to training and experience, as expected with any new skill set [49]. Furthermore, overall operating theatre time not only encompasses the primary surgical procedure, but also robotic system set up, patient positioning, robot docking, and additional tasks performed by the theatre team as a whole. In a similar fashion to the primary surgeon activity discussed above, the increased experience of adequately trained and well drilled theatre team can be expected to significantly reduced theatre times, allowing an increased case load for theatre lists.

While every surgical speciality performs unique technical tasks requiring specific equipment, liver surgery, to perhaps a greater extent than other forms of abdominal surgery, utilise a cornucopia of specific tools not common to other subspecialties. Ultrasonic probes, used for intra operative identification of specific lesion, hepatobiliary specific energy devices and minimally invasive articulated retractors, as well as ultrasonic surgical aspirators, which allow cavitation and aspiration of hepatocytes whilst sparing vascular and biliary structures, are not yet incorporated into standard robotic systems. This technology, however, already exists within the minimal access domain of laparoscopic surgery, so incorporation into robotic systems should not pose an insurmountable barrier.

An often described limitation of MIS is the relative lack of tactile feedback present in open surgery, making dissection of difficult but vital structures significantly more challenging, with potential for catastrophic tissue damage from excessive

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 open surgery [50, 51].

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 literature to avoid publication bias.

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

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 with hepatic robotic surgery in the obese patient cohort.

Operative training is a vital part of any health service in order to provide future 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 systems within healthcare institutions.
