TECHNICAL REPORT
Robot-assisted Laparoscopic Partial Caudate Lobe Resection for Hepatocellular Carcinoma in Cirrhotic Liver Eric C. H. Lai, MB ChB, MRCS(Ed), FRACS and Chung-Ngai Tang, MB BS, FRCS
Purpose: To evaluate the technical feasibility and safety of robotassisted laparoscopic partial caudate lobe resection using the robotic surgical system. Materials and Methods: This is a report of the use of robot-assisted laparoscopic partial caudate lobe resection on 2 patients with hepatocellular carcinoma. Results: Robot-assisted laparoscopic partial caudate lobe resection was completed successfully in these 2 patients. The operating time was 137 and 150 minutes, respectively. The blood loss was 137 and 150 mL, respectively. They were able to tolerate liquids on the second postoperative day. Both patients recovered from the operation. They were discharged 4 and 5 days after the operation, respectively. The resected margins of both specimens were tumor free (R0 resections). Conclusions: Robot-assisted laparoscopic partial caudate lobe resection is a feasible and safe procedure. Our results demonstrate the advantages of robotic system on short-term outcomes and suggest the extended indication of minimally invasive hepatectomy even in the technically challenging anatomic area. Key Words: hepatocellular carcinoma, liver neoplasm, caudate lobe, hepatectomy, robot, laparoscopy
postoperative course after laparoscopic hepatectomy may also be improved in patients with liver cirrhosis because the abdominal wall is preserved, kinetics of the diaphragm are improved, collateral venous drainage is better, and there is less postoperative ascites. The current accepted indication includes peripherally located small hepatic tumors without vascular invasion.5 Laparoscopic hepatectomy for liver lesions arising from the caudate lobe have only been reported rarely.6–8 The recent introduction of robotic surgical systems has revolutionized the field of minimally invasive surgery. It was developed to overcome the disadvantages of traditional laparoscopic surgery. Well-known advantages of the robotic system such as improved vision using the 3-dimensional view, magnification, tremor suppression, and the flexibility of the instruments have allowed precise operating techniques in a variety of procedures in general surgery.9–12 These features allow the surgeon to perform delicate tissue dissection and precise intracorporeal suturing. Robotic surgery is gaining popularity for gastrointestinal surgery; however, its use in the liver surgery is reported scarcely. To the best of our knowledge, robotic approach of caudate lobe resection has not been reported in the literature before.
(Surg Laparosc Endosc Percutan Tech 2014;24:e88–e91)
C
audate lobe has its unique and complex anatomic characteristics in the liver anatomy.1,2 Because of the deep location of the caudate lobe and its proximity to great vessels, caudate lobectomy has long been considered as technically difficult. Caudate lobectomy is classified by complete and partial resection, and it is also classified by isolated and combined resection. Four surgical approaches, including right side, left side, combined, and anterior transhepatic, are used to perform caudate lobectomy.3 Choice of surgical approaches depends on size, location of lesion, severity of liver cirrhosis, and general condition of the patient. The development of minimally invasive surgery over the last 2 decades has a great impact on the surgical practice. The advantages of laparoscopic hepatectomy are those of minimally invasive surgery, such as early recovery, shorter hospital stay, and better cosmetic outcome.4 The Received for publication March 11, 2013; accepted May 6, 2013. From the Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China. The authors declare no conflict of interest. Reprints: Eric C.H. Lai, MB ChB, MRCS(Ed), FRACS, Department of Surgery, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong SAR, China (e-mail: ericlai@ alumni.cuhk.edu.hk). Copyright r 2014 by Lippincott Williams & Wilkins
e88 | www.surgical-laparoscopy.com
FIGURE 1. Port sites.
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 3, June 2014
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 3, June 2014
Robotic Caudate Lobe Resection
The robotic system may help to extend the indication for minimally invasive hepatectomy in future. Herein, we present 2 cases of robot-assisted laparoscopic partial caudate lobe resection for hepatocellular carcinoma (HCC).
MATERIALS AND METHODS Use of the robotic system for general surgery at our hospital began in May 2009. The da Vinci S Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) was used for all robotic-assisted procedures. Since then, a prospectively designed database has tracked all robot-assisted procedure. Patient demographics, underlying pathology, procedures, and data on preoperative and postoperative monitoring including complications and length of hospital stay were recorded in the database. All operations were performed by consultant surgeons with great experience in the conventional laparoscopic technique. We have operated on 2 patients with HCC in caudate lobe in cirrhotic liver.
Operative Technique The surgery was performed on the patient in a supine position with both legs splitting apart on the operating table, under general anesthesia. A 12-mm subumbilical camera port was placed by open technique, and pneumoperitoneum was achieved by CO2 insufflation. A 30-degree laparoscope was introduced. Under the laparoscopic view, 3 additional 8-mm robotic instrument ports and a 12-mm conventional laparoscopic working port were placed (Fig. 1). The 12-mm operative port over right side of the abdomen was used for suction, irrigation, passing of needle stitches during intracorporeal suturing, and passing of ultrasonic dissector or endostapler. The patient was tilted to the reverse Trendelenburg position. Staging laparoscopy and laparoscopic ultrasound were performed. Thereafter, the robotic surgical cart was docked in. The chief surgeon was seated at the robotic console, while an assistant surgeon was positioned on the right side of the patient. The robotic camera arm and the other 3 instrument arms were then connected to their respective ports. Central venous pressure was maintained at
Robot-assisted Laparoscopic Partial Caudate Lobe Resection for Hepatocellular Carcinoma in Cirrhotic Liver Eric C. H. Lai, MB ChB, MRCS(Ed), FRACS and Chung-Ngai Tang, MB BS, FRCS
Purpose: To evaluate the technical feasibility and safety of robotassisted laparoscopic partial caudate lobe resection using the robotic surgical system. Materials and Methods: This is a report of the use of robot-assisted laparoscopic partial caudate lobe resection on 2 patients with hepatocellular carcinoma. Results: Robot-assisted laparoscopic partial caudate lobe resection was completed successfully in these 2 patients. The operating time was 137 and 150 minutes, respectively. The blood loss was 137 and 150 mL, respectively. They were able to tolerate liquids on the second postoperative day. Both patients recovered from the operation. They were discharged 4 and 5 days after the operation, respectively. The resected margins of both specimens were tumor free (R0 resections). Conclusions: Robot-assisted laparoscopic partial caudate lobe resection is a feasible and safe procedure. Our results demonstrate the advantages of robotic system on short-term outcomes and suggest the extended indication of minimally invasive hepatectomy even in the technically challenging anatomic area. Key Words: hepatocellular carcinoma, liver neoplasm, caudate lobe, hepatectomy, robot, laparoscopy
postoperative course after laparoscopic hepatectomy may also be improved in patients with liver cirrhosis because the abdominal wall is preserved, kinetics of the diaphragm are improved, collateral venous drainage is better, and there is less postoperative ascites. The current accepted indication includes peripherally located small hepatic tumors without vascular invasion.5 Laparoscopic hepatectomy for liver lesions arising from the caudate lobe have only been reported rarely.6–8 The recent introduction of robotic surgical systems has revolutionized the field of minimally invasive surgery. It was developed to overcome the disadvantages of traditional laparoscopic surgery. Well-known advantages of the robotic system such as improved vision using the 3-dimensional view, magnification, tremor suppression, and the flexibility of the instruments have allowed precise operating techniques in a variety of procedures in general surgery.9–12 These features allow the surgeon to perform delicate tissue dissection and precise intracorporeal suturing. Robotic surgery is gaining popularity for gastrointestinal surgery; however, its use in the liver surgery is reported scarcely. To the best of our knowledge, robotic approach of caudate lobe resection has not been reported in the literature before.
(Surg Laparosc Endosc Percutan Tech 2014;24:e88–e91)
C
audate lobe has its unique and complex anatomic characteristics in the liver anatomy.1,2 Because of the deep location of the caudate lobe and its proximity to great vessels, caudate lobectomy has long been considered as technically difficult. Caudate lobectomy is classified by complete and partial resection, and it is also classified by isolated and combined resection. Four surgical approaches, including right side, left side, combined, and anterior transhepatic, are used to perform caudate lobectomy.3 Choice of surgical approaches depends on size, location of lesion, severity of liver cirrhosis, and general condition of the patient. The development of minimally invasive surgery over the last 2 decades has a great impact on the surgical practice. The advantages of laparoscopic hepatectomy are those of minimally invasive surgery, such as early recovery, shorter hospital stay, and better cosmetic outcome.4 The Received for publication March 11, 2013; accepted May 6, 2013. From the Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China. The authors declare no conflict of interest. Reprints: Eric C.H. Lai, MB ChB, MRCS(Ed), FRACS, Department of Surgery, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong SAR, China (e-mail: ericlai@ alumni.cuhk.edu.hk). Copyright r 2014 by Lippincott Williams & Wilkins
e88 | www.surgical-laparoscopy.com
FIGURE 1. Port sites.
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 3, June 2014
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 3, June 2014
Robotic Caudate Lobe Resection
The robotic system may help to extend the indication for minimally invasive hepatectomy in future. Herein, we present 2 cases of robot-assisted laparoscopic partial caudate lobe resection for hepatocellular carcinoma (HCC).
MATERIALS AND METHODS Use of the robotic system for general surgery at our hospital began in May 2009. The da Vinci S Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) was used for all robotic-assisted procedures. Since then, a prospectively designed database has tracked all robot-assisted procedure. Patient demographics, underlying pathology, procedures, and data on preoperative and postoperative monitoring including complications and length of hospital stay were recorded in the database. All operations were performed by consultant surgeons with great experience in the conventional laparoscopic technique. We have operated on 2 patients with HCC in caudate lobe in cirrhotic liver.
Operative Technique The surgery was performed on the patient in a supine position with both legs splitting apart on the operating table, under general anesthesia. A 12-mm subumbilical camera port was placed by open technique, and pneumoperitoneum was achieved by CO2 insufflation. A 30-degree laparoscope was introduced. Under the laparoscopic view, 3 additional 8-mm robotic instrument ports and a 12-mm conventional laparoscopic working port were placed (Fig. 1). The 12-mm operative port over right side of the abdomen was used for suction, irrigation, passing of needle stitches during intracorporeal suturing, and passing of ultrasonic dissector or endostapler. The patient was tilted to the reverse Trendelenburg position. Staging laparoscopy and laparoscopic ultrasound were performed. Thereafter, the robotic surgical cart was docked in. The chief surgeon was seated at the robotic console, while an assistant surgeon was positioned on the right side of the patient. The robotic camera arm and the other 3 instrument arms were then connected to their respective ports. Central venous pressure was maintained at
