**3.2 Indications for liver surgery**

Most liver operations are performed for the management of both benign and malignant hepatic tumours. **Table 1** demonstrates the frequency of these liver operations.

The vast majority of liver operations performed for metastatic liver disease are for colorectal liver metastasis, approximately 80% of all liver operations are performed for liver cancer. Other metastatic diseases considered for liver resection include neuroendocrine tumours and sarcoma. The most common primary malignant tumour of the liver is the hepatocellular carcinoma (HCC) and in patients with preserved liver function, hepatectomy can be considered. Importantly in patients were the liver is damaged or cirrhotic, liver surgery cannot be undertaken, as the liver will not regenerate. Cholangiocarcinoma is the other common primary liver tumour and in cases where there is no metastatic/extrahepatic disease hepatectomy as listed in **Figure 2** can be considered. Benign tumours include hepatocellular adenoma, hepatic haemangioma and focal nodular hyperplasia can be considered for liver resection in selected patients particularly if symptomatic. Hepatectomy may also be the procedure of choice to treat intrahepatic gallstones or parasitic

#### **Figure 2.**

*The different types of hepatectomy. Liver resections are classified based upon the segments of the liver that are resected. A right hepatectomy/lobectomy is surgical resection of segments 5, 6, 7 and 8 whereas a left hepatectomy/lobectomy constitutes resection of segments 2, 3, 4. An extended left hepatectomy involves the further resection of segments 5 and 8. Combining a resection of segment 4 with a right hepatectomy is a classified as an extended right hepatectomy. Resection of a named segment is termed a segmentectomy and two contiguous segments a bi-segmentectomy. Resections crossing anatomical planes irrelevant of size are classified as non-anatomical resections.*


**Table 1.**

*Indications for liver resections.*

cysts of the liver. Some of these pathologies such as HCC are also indications for liver transplantation but these indications and surgical techniques are outside the scope of this chapter. In the modern era liver surgery is safe when performed by experienced surgeons with appropriate technological and institutional support. As with most major surgical procedures, there is a tendency towards improved patient outcomes in high volume centres. Apart from liver surgery for trauma or HCC in cirrhotic patients where the mortality is high [1], the overall operative mortality for liver resections is now reported in the worldwide between 0 and 2% [2, 3]. This is a great advance in comparison to the mortality in liver surgery in early reports, which reached a mortality rate as high as 20% [4].

### **4. Evolution of robotic liver surgery**

The German surgeon Carl Johann August Langenbuch was the first surgeon to perform a successful hepatic resection in 1888 [5]. The field of liver surgery did not advance significantly until the 1950s at which time liver surgery remained associated with high patient mortality with ill-defined surgical indications [6, 7] In 1952 Lortat Jacob published his surgical techniques of anatomical liver resection [8] whilst in 1956, Claude Couinaud [9, 10] published his seminal work on the segmental anatomy of the liver which forms the basis of modern liver surgery. The application of these findings was restricted due to the persisting high-risk nature of liver surgery and the inadequate nature of liver imaging. However the advent of intraoperative ultrasound (IOUS) in the early 1980s [11] allowed for the identification of smaller liver lesions that can be resected leading to the rapid expansion of open liver surgery [12]. The technique of IOUS allowed the surgeon to understand liver vasculature and biliary duct anatomy improving the precision and safety of surgery. Within the next decade the first reports of laparoscopic liver wedge resection were published [13] which was followed by laparoscopic major hepatectomy in the mid 1990s [14]. The Second International Consensus Conference in 2014 recommended that laparoscopic resection to be standard of practice for selected anterolateral minor liver resections [15]. This entailed that lesions in segments 2, 3, 4b, 5 and 6 should be considered for laparoscopic liver resection.

There is a common misconception that robotic liver surgery evolved from laparoscopic liver surgery but robotic surgery has developed in tandem with the former. Computer Motion Inc. and Intuitive Surgical Inc. independently developed robotic surgical systems in the 1990s. In 1999, Intuitive Surgical released the da Vinci robot in Europe. The da Vinci robot is made up of three components (**Figure 3**):

**219**

**Figure 3.**

*as visual annotation and video recording.*

*Robotic Liver Surgery*

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

tion and port placement (**Figure 3**) [18].

a surgeon console, a 4-armed patient cart that is docked against the operating table, and a vision cart. The robot as a high-definition 3-dimensional viewer, a footswitch that conveniently allows the surgeon to seamlessly move between the camera, retractors, and instrument control, and the Endowrist instruments. Importantly the Endowrist instruments are articulated in a manner that allows a greater degree of motion that the human wrist [16] (see below). In 2003, Intuitive Surgical and Computer Motion merged and during this time the first reports of robotic liver resections were published. Marescaux *et al*. reported the first transatlantic robotassisted telesurgery in 2001, where a robotic cholecystectomy was performed by surgeons in New York, USA, and the patient in Strasbourg, France [17]. The second generation da Vinci S was released in 2006, and in 2014, the fourth generation da Vinci Xi robot was approved by the FDA, with a redesigned surgical arm cart, smaller, longer arms, and new camera system to allow more flexibility in cart posi-

*The Da Vinci xi system. (a) Illustrates the current 4th generation da Vinci xi® robotic system. The system consists of three separate components; the patient cart, vision cart and surgeon cart (left to right). (b) Demonstrates the set-up of the robotic system in an operating theatre. Operating surgeons can sit unscrubbed at the surgeon console away from the operating table where the sterile patient cart is docked to the patient. The vision cart allows the other theatre staff to view the surgical field and allow the use of ancillary functions such* 

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

*Liver Disease and Surgery*

**Table 1.**

*Indications for liver resections.*

cysts of the liver. Some of these pathologies such as HCC are also indications for liver transplantation but these indications and surgical techniques are outside the scope of this chapter. In the modern era liver surgery is safe when performed by experienced surgeons with appropriate technological and institutional support. As with most major surgical procedures, there is a tendency towards improved patient outcomes in high volume centres. Apart from liver surgery for trauma or HCC in cirrhotic patients where the mortality is high [1], the overall operative mortality for liver resections is now reported in the worldwide between 0 and 2% [2, 3]. This is a great advance in comparison to the mortality in liver surgery in early reports, which

**Indication for liver surgery Frequency (%)** Metastatic disease 51–55 Primary liver malignancy 14–16 Benign liver malignancy 8–11 Biliary tract malignancy 3–5 Benign liver disease 2–4 Benign biliary disease 1–4 Trauma 4–8 Other 3–6

The German surgeon Carl Johann August Langenbuch was the first surgeon to perform a successful hepatic resection in 1888 [5]. The field of liver surgery did not advance significantly until the 1950s at which time liver surgery remained associated with high patient mortality with ill-defined surgical indications [6, 7] In 1952 Lortat Jacob published his surgical techniques of anatomical liver resection [8] whilst in 1956, Claude Couinaud [9, 10] published his seminal work on the segmental anatomy of the liver which forms the basis of modern liver surgery. The application of these findings was restricted due to the persisting high-risk nature of liver surgery and the inadequate nature of liver imaging. However the advent of intraoperative ultrasound (IOUS) in the early 1980s [11] allowed for the identification of smaller liver lesions that can be resected leading to the rapid expansion of open liver surgery [12]. The technique of IOUS allowed the surgeon to understand liver vasculature and biliary duct anatomy improving the precision and safety of surgery. Within the next decade the first reports of laparoscopic liver wedge resection were published [13] which was followed by laparoscopic major hepatectomy in the mid 1990s [14]. The Second International Consensus Conference in 2014 recommended that laparoscopic resection to be standard of practice for selected anterolateral minor liver resections [15]. This entailed that lesions in segments 2, 3, 4b, 5 and 6

There is a common misconception that robotic liver surgery evolved from laparoscopic liver surgery but robotic surgery has developed in tandem with the former. Computer Motion Inc. and Intuitive Surgical Inc. independently developed robotic surgical systems in the 1990s. In 1999, Intuitive Surgical released the da Vinci robot

in Europe. The da Vinci robot is made up of three components (**Figure 3**):

reached a mortality rate as high as 20% [4].

**4. Evolution of robotic liver surgery**

should be considered for laparoscopic liver resection.

**218**

a surgeon console, a 4-armed patient cart that is docked against the operating table, and a vision cart. The robot as a high-definition 3-dimensional viewer, a footswitch that conveniently allows the surgeon to seamlessly move between the camera, retractors, and instrument control, and the Endowrist instruments. Importantly the Endowrist instruments are articulated in a manner that allows a greater degree of motion that the human wrist [16] (see below). In 2003, Intuitive Surgical and Computer Motion merged and during this time the first reports of robotic liver resections were published. Marescaux *et al*. reported the first transatlantic robotassisted telesurgery in 2001, where a robotic cholecystectomy was performed by surgeons in New York, USA, and the patient in Strasbourg, France [17]. The second generation da Vinci S was released in 2006, and in 2014, the fourth generation da Vinci Xi robot was approved by the FDA, with a redesigned surgical arm cart, smaller, longer arms, and new camera system to allow more flexibility in cart position and port placement (**Figure 3**) [18].

#### **Figure 3.**

*The Da Vinci xi system. (a) Illustrates the current 4th generation da Vinci xi® robotic system. The system consists of three separate components; the patient cart, vision cart and surgeon cart (left to right). (b) Demonstrates the set-up of the robotic system in an operating theatre. Operating surgeons can sit unscrubbed at the surgeon console away from the operating table where the sterile patient cart is docked to the patient. The vision cart allows the other theatre staff to view the surgical field and allow the use of ancillary functions such as visual annotation and video recording.*
