**7. Current advantages and disadvantages of robotic liver surgery**

The utility of robotic liver surgery in part lies in the fact that it can overcome some of the inherent difficulties associated with laparoscopic liver surgery. For instances both these minimal access approaches to liver surgery entail long operative times and in the case of laparoscopic liver surgery this involves enduring unfavourable ergonomics during surgery primarily because of rigid laparoscopic instruments coupled with the primary operator having to remain scrubbed at the table side for extended periods of time. In the robotic liver surgery the primary operator being unscrubbed at the surgeon cart whilst operating and tailoring the console ergonomics to suit their individual preference overcomes these particular constraints. The benefits to the operating surgeon are clear namely operating in an ergonomically comfortable position with a 3-D view of the surgical field that aids depth perception. In addition the surgeon maintains control of the endoscope mitigating unnecessary camera movements and ensuring stable surgical views throughout the procedure. Robotic-assisted retractors are also controlled by the operating surgeon and maintain their position until further movement/retraction is required further avoiding inappropriate or ineffective retraction. Furthermore the use of articulated instruments that mimic the dexterity of the human hand allows for precise tissue manipulation and suturing in restricted surgical fields at angles not possible with rigid instruments. For instance Intuitive's multi-functional da Vinci instruments incorporate EndoWrist® technology (**Figure 6**).

The Endowrist® is incorporated into each Intuitive instrument (e.g. graspers, needle drivers and energy devices) and has a greater range of movement than the human hand. In addition robotic systems have in-built tremor reduction enhancing fingertip control. The Endowrist® technology also facilitates curved transection lines during liver surgery allowing for more complex liver resections to be performed. The technology also allows for the creation of biliary and enteric anastomoses in restricted surgical fields. During robotic surgery the surgeon's motions are scaled so that small, precise movements are effected at the patient's end which when fashioning a hepaticojejunostomy has significant advantages.

#### **Figure 6.**

*Endowrist robotic instruments. Robotic instruments incorporate Endowrist technology that allows the operator to control various instruments via the fingers switches. The Endowrist allows more degrees of movement than the human hand.*

Emerging reports suggests that the learning curve for robotic surgery may be shorter when compared with conventional laparoscopic surgery. However this may be due to the fact that many surgeons have previously obtained proficiency with laparoscopic surgery before engaging with robotic surgery. Currently complex laparoscopic liver resections are generally performed by surgeons who are experienced hepatobiliary/laparoscopic surgeons. Open surgical techniques are more readily translated to robotics and thus surgeons who are expert in open hepatobiliary surgery but not necessarily advanced laparoscopy may become proficient quicker with robotic hepatectomy. Robotic surgery lends itself well to computer based virtual reality training and as such trainee robotic surgeons may develop and attain significant competence with the robotic platform prior to operating on real patients. Such training systems have been developed and validated. Studies have found that structured training exercises improved simulator performance, although the translation to actual surgical performance has not been well studied [23]. Although the robotic dual console is also a teaching tool that could help accelerate proficiency. In addition port placement is more forgiving in robotic surgery as instruments are not completely restricted by a rigid fulcrum and also compensated for by the Endowrist®. The details of port placement are discussed further in Section 8 below.

Although the development of robotic surgery is developing quickly there are a number of disadvantages with the current operating systems. The current generation of robots require a large amount of space in theatre to accommodate each of the three components as well as the patient and anaesthetic equipment. In additions bulky arms can prove difficult to manoeuvre in the space between theatre operating lights. Spacious operating rooms are require and dexterity is limited by collision of robotic arms (**Figure 3**). Importantly a skilled assistant is needed for suction, change of instruments, application of argon plasma, and stapling. In addition if an assistant port is required this will need the assistant to operate an instrument through it and thus requires some element of laparoscopic skills. However newer robotic instruments such as robotic suction devices, sealers, and staplers has eliminated the routine need for accessory ports and necessity of a skilled bedside assistant. Although

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*Robotic Liver Surgery*

steps of the operation.

prospectively collected data.

**8.2 Patient positioning and robot docking**

**8. Technique of robotic liver resection**

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

the robotic equivalent of CUSA is eagerly awaited which is likely to improve the division of the liver and the scope of liver surgery if and when available. Although there is improved depth perception with the robotic platform there is no tactile feedback and thus retraction force has to be judged and maintained by the operating surgeon. Although not strictly a problem limited to robotic surgery if the patient position requires adjustment this will often necessitates the robotic arms to be undocked, the robot to be moved and the robot arms to be redocked (see below). This will add time to the overall operating procedure and will also mean that an experienced theatre team is needed to carry this out smoothly with no loss of sterility. For similar reasons the ability to convert a robotic surgical procedure to an open procedure for emergencies such as bleeding requires a skilled team that can coordinate undocking of the robot, removal of the robotic instrumentation and conversion to laparotomy. The latest Intuitive Xi robot that allows a greater simplicity in manoeuvring the robotic components without having to move the operating table, patient cart or standard

Robot and robotic malfunction is a known phenomenon and many of these problem require a replacement of robotic instruments [24]. One of the major disadvantages of robotic surgery is the high cost and this is multifaceted. Aside from the purchase of the platform and equipment there are costs incurred for consumables, surgeon and staff training as well as servicing costs for the robot. Although many of these may be offset by shorter length of ITU stay and shorter hospital stay. One of the limits of robotic HPB surgery is the need for specialised training, not only for the primary surgeon, but also for the assistant surgeon and OR nurses, although in some cases, the learning curve for specific robotic procedures has proven to be shorter than the laparoscopic equivalent [25]. A specific issue for liver surgeons is that at present only a limited number of instruments are available parenchymal transection such as harmonic shears. Although these remain an efficient tool as discussed above the development of a robotic CUSA would improve the mechanical

theatre equipment has overcome many of these logistical issues.

**8.1 General consideration for patients undergoing liver surgery**

All patients considered for robotic liver surgery should have the same workup as for patients undergoing any form of liver surgery. Patients must have the physiological reserve to tolerate general anaesthesia and a prolonged pneumoperitoneum. In our institution all patients undergo cardiopulmonary exercise testing and routine haematology, coagulation and biochemistry as part of anaesthetic workup. General contraindications to laparoscopy such as uncorrected coagulopathy and cardio-respiratory compromise should be observed. Furthermore patients should be discussed in an appropriate multidisciplinary team meeting after cross-sectional imaging and staging. In our institution all patient undergo Computed Tomography (CT) of the thorax, abdomen and pelvis. We use MRI liver and CT-PET on a patient-dependent manner. Patients also give informed consent for robotic surgery and we quote a robot to open conversion rate of 10% in our unit based upon our unit

Following general anaesthesia the patient is placed in the supine position and strapped into position on the operating table. Depending upon the type of liver

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

*Liver Disease and Surgery*

**Figure 6.**

*the human hand.*

Emerging reports suggests that the learning curve for robotic surgery may be shorter when compared with conventional laparoscopic surgery. However this may be due to the fact that many surgeons have previously obtained proficiency with laparoscopic surgery before engaging with robotic surgery. Currently complex laparoscopic liver resections are generally performed by surgeons who are experienced hepatobiliary/laparoscopic surgeons. Open surgical techniques are more readily translated to robotics and thus surgeons who are expert in open hepatobiliary surgery but not necessarily advanced laparoscopy may become proficient quicker with robotic hepatectomy. Robotic surgery lends itself well to computer based virtual reality training and as such trainee robotic surgeons may develop and attain significant competence with the robotic platform prior to operating on real patients. Such training systems have been developed and validated. Studies have found that structured training exercises improved simulator performance, although the translation to actual surgical performance has not been well studied [23]. Although the robotic dual console is also a teaching tool that could help accelerate proficiency. In addition port placement is more forgiving in robotic surgery as instruments are not completely restricted by a rigid fulcrum and also compensated for by the Endowrist®. The details of port placement are discussed further in Section 8 below. Although the development of robotic surgery is developing quickly there are a number of disadvantages with the current operating systems. The current generation of robots require a large amount of space in theatre to accommodate each of the three components as well as the patient and anaesthetic equipment. In additions bulky arms can prove difficult to manoeuvre in the space between theatre operating lights. Spacious operating rooms are require and dexterity is limited by collision of robotic arms (**Figure 3**). Importantly a skilled assistant is needed for suction, change of instruments, application of argon plasma, and stapling. In addition if an assistant port is required this will need the assistant to operate an instrument through it and thus requires some element of laparoscopic skills. However newer robotic instruments such as robotic suction devices, sealers, and staplers has eliminated the routine need for accessory ports and necessity of a skilled bedside assistant. Although

*Endowrist robotic instruments. Robotic instruments incorporate Endowrist technology that allows the operator to control various instruments via the fingers switches. The Endowrist allows more degrees of movement than* 

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the robotic equivalent of CUSA is eagerly awaited which is likely to improve the division of the liver and the scope of liver surgery if and when available. Although there is improved depth perception with the robotic platform there is no tactile feedback and thus retraction force has to be judged and maintained by the operating surgeon. Although not strictly a problem limited to robotic surgery if the patient position requires adjustment this will often necessitates the robotic arms to be undocked, the robot to be moved and the robot arms to be redocked (see below). This will add time to the overall operating procedure and will also mean that an experienced theatre team is needed to carry this out smoothly with no loss of sterility. For similar reasons the ability to convert a robotic surgical procedure to an open procedure for emergencies such as bleeding requires a skilled team that can coordinate undocking of the robot, removal of the robotic instrumentation and conversion to laparotomy. The latest Intuitive Xi robot that allows a greater simplicity in manoeuvring the robotic components without having to move the operating table, patient cart or standard theatre equipment has overcome many of these logistical issues.

Robot and robotic malfunction is a known phenomenon and many of these problem require a replacement of robotic instruments [24]. One of the major disadvantages of robotic surgery is the high cost and this is multifaceted. Aside from the purchase of the platform and equipment there are costs incurred for consumables, surgeon and staff training as well as servicing costs for the robot. Although many of these may be offset by shorter length of ITU stay and shorter hospital stay. One of the limits of robotic HPB surgery is the need for specialised training, not only for the primary surgeon, but also for the assistant surgeon and OR nurses, although in some cases, the learning curve for specific robotic procedures has proven to be shorter than the laparoscopic equivalent [25]. A specific issue for liver surgeons is that at present only a limited number of instruments are available parenchymal transection such as harmonic shears. Although these remain an efficient tool as discussed above the development of a robotic CUSA would improve the mechanical steps of the operation.
