**Table 3.**


**231**

**Authors** Magistri et al. [40]

Morel P

2017

16

60

7:9

69%

352

NR

0

6

8

31

0

100

malignant

(all minor)

[41]

Wang et al.

2018

63

NR

43:20

All HCC,

296

206

NR

NR

NR

11

NR

94

1 major

hepatectomy

[42]

Ceccarelli

2018

70

NR

NR

26%

NR

NR

10

NR

NR

NR

0

NR

malignant

et al. [43]

Sucandy

2019

80

63

5:3

46% major

233

150

1

NR

3

14

1

NR

hepatectomy

et al. [44]

**Table 4.**

*Recent results of robotic liver surgery.*

2017

22

61

18:4

10% major hepatectomy

318

400 (50– 1500)

0

5

NR

59

0

96

**Year**

**n**

**Age**

**M:F**

**Resection type**

**Operative time (mins)**

**Blood loss (mins)**

**Conversion rate (%)**

**Transfusion rate (%)**

**Post-op stay (days)**

**Morbidity (%)**

**Mortality (%)**

**R0 (%)**

*Robotic Liver Surgery*

*DOI: http://dx.doi.org/10.5772/intechopen.87995*

*Liver Disease and Surgery*


*Robotic Liver Surgery DOI: http://dx.doi.org/10.5772/intechopen.87995*

*Liver Disease and Surgery*

**230**

**Authors** Tsung et al.

2014

57

58

42:58

37% major

253

200

7

4

4

20

0

95

(3–5.5)

(180–355)

(50–338)

hepatectomy

[31]

Spampinato

2014

25

63

13:12

Major

430

250

4

44

8 (4–22)

16

0

100

(240–725)

(100–

19,000)

(16 RHH;

17LHH)

et al. [32]

Tranchart

2014

28

66

13:15

All minor

210

200

14

14

6 (1–15)

14

0

NR

(45–480)

(0–1800)

et al. [27]

Wu et al.

2014

52

61

32:6

67% major

380

325

5

NR

8

8

0

NR

hepatectomy

[33]

Boggi et al.

2015

12

61

4:8

Superioposterior

260

252

8

25

NR

33

0

100

segments

[34]

Montalti R

2016

36

62

21:15

Superioposterior

306

415

14

NR

6 (2–91)

19

3

89

(53–790)

(0–1500)

segments

[35]

Lee et al.

2016

70

58

65:35

20% major

252

100

6

5

5

12

0

98

(2—22)

(97–620)

(2–2500)

hepatectomy

[36]

Lai et al.

2016

100

NR

NR

27% major

207

334

NR

NR

NR

14

0

96

hepatectomy

[37]

Croner

2016

10

64

2:8

All

321

306

NR

NR

7 (5–13)

10

0

100

(138–458)

malignant

et al. [38]

Nota et al.

2016

16

69

9:7

All minor

146

150

6

NR

4 (1–8)

43

0

NR

(60–265)

(5–600)

(81%

malignant

[39]

**Year**

**n**

**Age**

**M:F**

**Resection** 

**Operative** 

**Blood** 

**Conversion** 

**Transfusion** 

**Post-op** 

**Morbidity** 

**Mortality** 

**R0** 

**(%)**

**(%)**

**(%)**

**stay** 

**(days)**

**rate (%)**

**rate (%)**

**loss** 

**time** 

**(mins)**

**(mins)**

**type**

**Table 4.**

*Recent results of robotic liver surgery.*

#### **9.1 Results from robot liver resection**

Due to the less complex nature of surgery the most common robotic liver procedures performed globally are minor hepatectomy; segmentectomies (29%), left lateral sectionectomies (13%) and bisegmentectomies (9%). **Table 3** demonstrates the types and frequency of robotic hepatectomy.

This table illustrates the frequencies of the different types of robotic liver resections reported in the literature since 2013.

A recent meta-analysis published in 2013 has summarised the results of robotic liver resection up to 2013 [30]. The reader is directed here for the early results of robotic liver resection. In summary the number of major hepatectomies reported in the literature increased as experience with robotic surgery improved. The overall data suggested that robotic assisted liver surgery was comparable to both open and laparoscopic surgery in terms of peri-operative and postoperative outcomes, as well as oncologic efficacy. Complex procedures, such as extended liver resections were suggested to be technically easier due to the intrinsic advantages of the robotic system.

We discuss the results of robotic liver resection from 2013 to the current period. A number of selected studies reporting outcomes for robotic liver surgery since 2014 are shown in **Table 4**. This list is an exhaustive but highlights the progress that has been made worldwide in advancing robotic liver surgery. Achieving complete resection margins in liver surgery is critical for disease- and recurrence-free survival. It is currently still under investigation if minimal invasive techniques with reduced haptic feedback result in the same oncological results as open surgery. Unfortunately some studies still do not report complete resection rates (termed R0) in their data. However reviewing studies from 2014 onwards most report R0 resection rates of over 90% with many reporting 100%. The long-term outcome although is not well reported and many of these studies have not had the necessary follow-up time for this to be reported and this data is eagerly awaited. The limited studies that have been published appear to report equivalent disease-free and overall survival reported for HCC patients undergoing robotic-assisted versus laparoscopic liver surgery [37]. Although as discussed above robotic liver surgery carry increased costs the reported blood loss is in line with open and laparoscopic surgery and there is reassuringly low open conversion rate that is equivalent to laparoscopic surgery.

As the experience with robotic surgery has increased more recent studies have shown that the rate of major hepatectomy completed robotically has increased with low mortality. The morbidity however needs to be carefully interpreted as many studies report overall complications, that include minor complications, whereas as other has reported major complications only.

#### **10. The future of robotic liver surgery**

The robotic platform has distinct advantages over open and laparoscopic surgery and in some instances overcomes the limitations associated with these approaches. In particular the 3-D view, improved images and increased dexterity of operating improve the operators ability to carry out surgery without compromising patient safety. As demonstrated in this chapter the safety and feasibility of robotic liver surgery has been shown worldwide.

The future in robot liver surgery may lie in using this platform to perform more complex liver surgery such as extended liver resections or by incorporating digital technology into the operating system but most importantly the for the field to keep evolving there is a real need for randomised clinical trials. This will allow definition

**233**

**Author details**

*Robotic Liver Surgery*

**11. Conclusions**

**Conflict of interest**

*DOI: http://dx.doi.org/10.5772/intechopen.87995*

to the wider dissemination of this technology.

of benefits and demonstrate the real advantage of this approach for both patients and the surgical fraternity. The authors believe that will be the most effective route

The current data suggest that both major and minor robotic hepatectomy is a safe and effective procedure with equivalent patient outcomes in terms of morbidity and mortality and oncological resection. There remain some important limitations to the wider dissemination of this technology principally around cost, some around training and so with the platform itself. It is hoped that collaborations between industry, academia and surgeons will overcome these problems allowing robotic

liver surgery to be practiced widely and deliver patient benefit.

The authors have no conflict of interests to declare.

Ricky Harminder Bhogal\*, Stephanos Pericleous and Aamir Z. Khan

© 2019 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,

The Royal Marsden Hospital, London, United Kingdom

provided the original work is properly cited.

\*Address all correspondence to: ricky.bhogal@rmh.nhs.uk

of benefits and demonstrate the real advantage of this approach for both patients and the surgical fraternity. The authors believe that will be the most effective route to the wider dissemination of this technology.
