Living donor robotic right hepatectomy is the future: Or is it?

摘要

Potential conflict of interest: Nothing to report. See Article on Page 1509 Minimally invasive surgery (MIS) of the liver has evolved during the last 2 decades with outcomes now comparable to open surgery. Advantages include less pain and a faster postoperative recovery.1 However, MIS hepatectomy has a steep learning curve due to the complexity of liver anatomy, with hemorrhage and technical difficulty the most often reported causes for conversion to open surgery.2 The laparoscopic approach to the liver has traditionally included "pure laparoscopic," "hand‐assisted," and "hybrid" techniques. The hand‐assisted technique entails placement of a hand port through a minilaparotomy to help right lobe mobilization and retraction, whereas with the hybrid technique, lobe mobilization is performed laparoscopically and the parenchymal transection is done through a small laparotomy.3 The first reported laparoscopic liver resection, in the early 1990s, was a nonanatomic procedure. This was followed by left lateral segmentectomy and, finally, formal hemihepatectomy by the end of that decade. Subsequently, a number of large laparoscopic liver resection series were published, and today there are more than 9000 laparoscopic liver resection cases reported in the literature worldwide.4 At present, minor laparoscopic liver resection, especially of anterior segments, is standard practice. Formal large hepatectomies are still considered innovative and are performed only at experienced centers. Laparoscopic donor hepatectomy represents the ultimate benchmark of proficiency, requiring extensive knowledge and experience of both transplantation and MIS approaches. The left lateral segment is the most common graft procured by this approach, yet small series of left and right donor hepatectomies have been reported. Most right hepatectomies have been performed using the hybrid approach, and only a few cases have been performed using a pure laparoscopic technique.1 More recently, evolution of MIS technology has involved robotics. Compared with laparoscopy, this technology platform, where the surgeon operates from a console, has some advantages that include enhanced 3‐dimensional visualization and superior tissue dissection capacity. While application in gynecology and urology was robust from the inception, the application of the robot to the liver has developed at a much slower pace. This is due to anatomical hurdles, such as lobe mobilization, need for a culture change from surgeons accustomed to performing laparoscopic liver surgery, and cost. Nevertheless, the number of reported robotic liver cases has increased as centers have gained experience.2 In this issue of Liver Transplantation, the report authored by Chen et al.7 and titled "Robotic Liver Donor Right Hepatectomy: A Pure, Minimally Invasive Approach" represents the first case series of donor right hepatectomy completed with a pure minimally invasive approach using robotic technology. Between May 2013 and August 2015, the authors performed a total of 67 consecutive right hepatectomies for living donation: 13 of these were performed with a pure minimally invasive robotic approach and 54 were open. In preparation for this series of robotic cases, the same team had accumulated a 4‐year track record performing laparoscopic hepatectomies and subsequently performed 50 robotic lobectomies in the nondonor situations. This appreciation of the steepness of the learning curve is commendable. One note of caution is that the authors do not clearly specify how patients undergoing MIS were selected. There were no conversions to open surgery during the robotic procedure. Both groups had comparable blood loss, complication rates, and incidence of early allograft dysfunction (EAD). The robotic group required a significantly longer operative time (596 versus 383 minutes; P < 0.001). This noteworthy prolongation of operative time (nearly 10 hours) raises the question whether the incidence of deep vein thrombosis inc