**6. Robotic liver surgery**

As experience with major laparoscopic operations such as splenectomy and colectomy has increased the interest in applying minimally invasive techniques to liver resection were developed in tandem. Technical developments such as more sophisticated energy devices and articulated laparoscopic staplers have enabled surgeons to tackle liver resection laparoscopically in line with international recommendations [15]. Specifically, as discussed above, lesions in the antero-medial segments of the liver are particularly favourable for this approach. Some of the major technical challenges in liver surgery include the access to the IVC and major hepatic veins, dissection of a difficult hepatic hilum coupled with the propensity for the liver to bleed during transection. These difficulties are magnified during laparoscopic surgery due to the limitations in depth perception, restricted movement with rigid instruments and fixed fulcrum at the ports, unnatural ergonomics that can compound suturing to the liver particularly in presence of haemorrhage. There is also a steep learning curve with laparoscopic liver surgery making its practice outside high-volume centres difficult although the same situation exists with robotic liver surgery. As a result, the uptake of minimally invasive hepatectomy has been understandably slow and cautious. However with increasing experience, surgeons have gradually increased the difficulty and complexity of liver surgery undertaken. This has developed from staging laparoscopy and de-roofing of simple liver cysts to resecting lesions in accessible parts of the liver such as the left lateral sector and wedge resections from the anteroinferior segments, to major hepatectomies. However, certain liver procedures are considered technically challenging. These include patient who have undergone previous surgery in particular upper abdominal surgery/liver surgery, resections involving the caudate lobe, lesions in the posterior portion of the liver and in patients requiring bile duct resection with reconstruction. In 2008 following a consensus conference experts recommended that laparoscopic resection should be considered in patients with solitary lesions, lesions 5 cm or less and/or those lesions located in segments 2–6 [19]. Furthermore the conference recommended that laparoscopic resection of liver segments 7, 8 and 1 was not standard practice. In part these recommendations were based upon the access to and visualisation of these areas of the liver and resection of these areas of the liver with rigid instruments. Moreover resection of liver lesions in the segments VII and VIII are particularly challenging because of issues with surgical access and the technical challenges in maintaining a curved transection lines throughout surgery thereby maintaining margins and obtaining R0 resection. Hence some evidence suggests that such lesions are more likely to be resected using right hepatectomy. Whilst oncologically this cannot be faulted it does necessitates the loss of a significant amount of normal functioning liver mass [20]. The most recent guidelines however still suggest that laparoscopic and by extension robotic liver surgery should not be considered for extended hepatectomies, when concomitant biliary reconstruction is needed or when lesions involve major vascular structures [15].

In theory, robotic surgery is an ideal platform for telesurgery. The indications for robotic hepatectomy are very similar to those for laparoscopic hepatectomy. Both benign and malignant tumours can be resected robotically. Robotic hepatectomy overcomes many of the problems inherent in laparoscopic surgery. In particular instruments allow curved transection lines and better visualisation of the liver [21].

**223**

*Robotic Liver Surgery*

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

can be widely applied in robotic liver surgery.

EndoWrist® technology (**Figure 6**).

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

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

The utility of robotic liver surgery in part lies in the fact that it can overcome

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.

Thus the greatest theoretical advantage of robotic hepatectomy may lie in sectoral, segmental, or subsegmental resections in difficult to access positions that mitigate against large incisions and extensive mobilisation required in an open approach. On the other hand, major hepatectomies for malignant conditions, such as hilar cholangiocarcinomas, where large incisions are required for specimen extraction may be better served by a traditional open approach although with improving robotic technology these may soon follow under the indications for robotic hepatectomy. Image guided surgery is an evolving entity in liver surgery. The premise of this approach involves the use of pre-operative imaging being used to precision guide surgery. Some fields in surgery, such as orthopaedic surgery, have built up a significant amount of experience with this approach [22]. Essentially by using fixed bony landmarks on the body pre-operative images can be used as part of computer modelling systems to target organs and potentially lesion in real-time. Clearly the use of a mandatory console as part of robotic surgery means that such image-guided surgery can be made a routine part of surgery. For liver surgeons this would mean pre-emptive appreciation of vascular structures and the ability to carefully plan resection margins. However image-guidance surgery in hepatobiliary surgery remains a nascent field and further technological advances required before its use

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

*Liver Disease and Surgery*

**6. Robotic liver surgery**

facilities.

The cart also contains an electrosurgical unit, the light source for the 3D endoscope and a series of racks for optional auxiliary surgical equipment such as recording

As experience with major laparoscopic operations such as splenectomy and colectomy has increased the interest in applying minimally invasive techniques to liver resection were developed in tandem. Technical developments such as more sophisticated energy devices and articulated laparoscopic staplers have enabled surgeons to tackle liver resection laparoscopically in line with international recommendations [15]. Specifically, as discussed above, lesions in the antero-medial segments of the liver are particularly favourable for this approach. Some of the major technical challenges in liver surgery include the access to the IVC and major hepatic veins, dissection of a difficult hepatic hilum coupled with the propensity for the liver to bleed during transection. These difficulties are magnified during laparoscopic surgery due to the limitations in depth perception, restricted movement with rigid instruments and fixed fulcrum at the ports, unnatural ergonomics that can compound suturing to the liver particularly in presence of haemorrhage. There is also a steep learning curve with laparoscopic liver surgery making its practice outside high-volume centres difficult although the same situation exists with robotic liver surgery. As a result, the uptake of minimally invasive hepatectomy has been understandably slow and cautious. However with increasing experience, surgeons have gradually increased the difficulty and complexity of liver surgery undertaken. This has developed from staging laparoscopy and de-roofing of simple liver cysts to resecting lesions in accessible parts of the liver such as the left lateral sector and wedge resections from the anteroinferior segments, to major hepatectomies. However, certain liver procedures are considered technically challenging. These include patient who have undergone previous surgery in particular upper abdominal surgery/liver surgery, resections involving the caudate lobe, lesions in the posterior portion of the liver and in patients requiring bile duct resection with reconstruction. In 2008 following a consensus conference experts recommended that laparoscopic resection should be considered in patients with solitary lesions, lesions 5 cm or less and/or those lesions located in segments 2–6 [19]. Furthermore the conference recommended that laparoscopic resection of liver segments 7, 8 and 1 was not standard practice. In part these recommendations were based upon the access to and visualisation of these areas of the liver and resection of these areas of the liver with rigid instruments. Moreover resection of liver lesions in the segments VII and VIII are particularly challenging because of issues with surgical access and the technical challenges in maintaining a curved transection lines throughout surgery thereby maintaining margins and obtaining R0 resection. Hence some evidence suggests that such lesions are more likely to be resected using right hepatectomy. Whilst oncologically this cannot be faulted it does necessitates the loss of a significant amount of normal functioning liver mass [20]. The most recent guidelines however still suggest that laparoscopic and by extension robotic liver surgery should not be considered for extended hepatectomies, when concomitant biliary reconstruction is needed or when lesions involve major vascular structures [15].

In theory, robotic surgery is an ideal platform for telesurgery. The indications for robotic hepatectomy are very similar to those for laparoscopic hepatectomy. Both benign and malignant tumours can be resected robotically. Robotic hepatectomy overcomes many of the problems inherent in laparoscopic surgery. In particular instruments allow curved transection lines and better visualisation of the liver [21].

**222**

Thus the greatest theoretical advantage of robotic hepatectomy may lie in sectoral, segmental, or subsegmental resections in difficult to access positions that mitigate against large incisions and extensive mobilisation required in an open approach. On the other hand, major hepatectomies for malignant conditions, such as hilar cholangiocarcinomas, where large incisions are required for specimen extraction may be better served by a traditional open approach although with improving robotic technology these may soon follow under the indications for robotic hepatectomy.

Image guided surgery is an evolving entity in liver surgery. The premise of this approach involves the use of pre-operative imaging being used to precision guide surgery. Some fields in surgery, such as orthopaedic surgery, have built up a significant amount of experience with this approach [22]. Essentially by using fixed bony landmarks on the body pre-operative images can be used as part of computer modelling systems to target organs and potentially lesion in real-time. Clearly the use of a mandatory console as part of robotic surgery means that such image-guided surgery can be made a routine part of surgery. For liver surgeons this would mean pre-emptive appreciation of vascular structures and the ability to carefully plan resection margins. However image-guidance surgery in hepatobiliary surgery remains a nascent field and further technological advances required before its use can be widely applied in robotic liver surgery.
