Selecting incision-dominant cases for robotic liver resection: towards outpatient hepatectomy with rapid recovery

Abstract

Background: The premise of minimally invasive surgery (MIS) is to minimize facial and muscle injury in order to enhance recovery from surgery. Robotic MIS surgery for resection of tumors in solid organs is gaining traction, though clear superiority of this approach is lacking and robotic surgery is more expensive. Our philosophy in robotically-assisted hepatectomy has been to employ this approach for cases where location of tumors make difficult a classical laparoscopic approach (superior/posterior tumors), and cases where the incision for an open operation dominates the course of recovery.

Methods: This is a retrospective review of a prospectively collected database.

Results: In this study we report 97 cases of liver resection subjected to the robotic approach, of which 90% were resected robotically. The mean operative time was 186±9 min; mean blood loss was 111±15 mL, and complications occurred in 9%. Two thirds of the patients remained in hospital 3 days or less, including three patients subjected to hemihepatectomy (2 left and 1 right). Fourteen individuals were discharged on the same day. The strongest predictors of long hospital stay (>3 days) were major hepatectomy (P=0.007), complications (P=0.008), and operative time >210 min (P=0.001).

Conclusions: With thoughtful case selection, this is a first demonstration that hepatectomy can be conducted as an out-patient or short-stay procedure.

Keywords: Adoption of minimally invasive surgery (MIS); enhanced recovery after surgery (ERAS); robotic MIS hepatectomy; surgical outcome.

Figure 1

Representative patient undergoing robotic right hepatectomy. (A) CT scan of a 42-year-old patient with metastatic cancer in segment 6, 7 and 8 of liver. Involvement of the junction of the right anterior and posterior pedicles resulted in compensatory hypertrophy of the left liver. Note large left liver as demarcated by the middle hepatic vein (arrow); (B,C) this patient also has involvement of the diaphragm requiring in-continuity resection of the right diaphragm and primary repair; (D) the data form the Vivofit fitness monitoring device. Note that the patient was back to 6,000 steps at Day 4 post-operatively.

Figure 2

Length of hospital stay for robotic hepatectomy according to minor or major (≥3 segments).