Key steps of complex robotic liver surgery: an international expert survey
Noa L E Aegerter, Christoph Kuemmerli, Felix Nickel, Cristiano Guidetti, Christoph Tschuor, Víctor López‐López, Taiga Wakabayashi, Philipp Dutkowski, Adrian T. Billeter, Beat P. Müller‐Stich, Philip C. Müller, Complex Robotic Liver Surgery Group, Yuta Abe, Mohammad Abu Hilal, Jawad Ahmad, Luca Aldrighetti, Adnan Alseidi, Ugo Boggi, Dieter C. Bröring, Hop S. Tran Cao, Yee Lee Cheah, Roland S. Croner, Fabrizio Di Benedetto, Alessandro Ferrero, David A. Geller, Stefan Gilg, Brian K. P. Goh, Jeroen Hagendoorn, Jason Hawksworth, Jin He, Asmus Heumann, Mathieu D’Hondt, Jan Philipp Jonas, Yoshikuni Kawaguchi, Philipp Kron, Jae‐Hoon Lee, Mickaël Lesurtel, Chétana Lim, Charles Chung-Wei Lin, Georg Lurje, Marcel Cerqueira César Machado, John B. Martinie, Riccardo Memeo, Yutaka Nakano, Christian E. Oberkofler, Fabrizio Panaro, James O. Park, Hugo P. Marques, Johann Pratschke, Florian Primavesi, Nuh N. Rahbari, Francesca Ratti, Christoph Reißfelder, R Robles, Olivier Saint‐Marc, Olivier Scatton, Moritz Schmelzle, Daniel Seehofer, Olivier Soubrane, Patrick Starlinger, Stefan Stättner, B Strücker, Iswanto Sucandy, Robert P. Sutcliffe, Rutger‐Jan Swijnenburg, Christian Toso, Roberto Troisi, Go Wakabayashi, Roeland F. de Wilde
Abstract
BACKGROUND: Robotic liver surgery (RLS) has become the preferred minimally invasive approach for liver surgery. However, especially for complex RLS (C-RLS), key surgical steps such as preoperative preparation, intraoperative techniques, and training are often center-dependent and not standardized. The aim of this survey was to assess the international practice of key surgical steps during C-RLS among expert centers. METHODS: A cross-sectional survey was conducted among robotic liver surgeons with a minimum individual experience of 50 RLS to assess their practice during C-RLS. The survey consisted of 50 questions, distributed across three sections: training, preoperative planning, and intraoperative practice for C-RLS. RESULTS: 60 out of 71 experts completed the survey, corresponding to an 85% response rate. 73% of the experts agreed that the IWATE difficulty score represents an adequate classification system to define C-RLS. A prerequisite before performing C-RLS was experience in complex open liver surgery (71%) and expertise in low and intermediate RLS (75%). Mentoring by a more experienced surgeon was deemed necessary by most experts (90%) when performing C-RLS. Vascular inflow control was mentioned to often be performed during parenchyma transection either selectively (38%) or routinely (52%). Most experts considered pre- or intraoperative positive staining helpful (57%), while negative staining (85%) was reported as even more important in C-RLS. For vasculo-biliary transection, experts preferred an intrafascial (45%), glissonian pedicle approach (33%) or a case-dependent transection (12%). For parenchymal transection, the preferred instruments were laparoscopic CUSA (92%), harmonic ACE (78%), and SynchroSeal (77%). CONCLUSION: This expert survey reveals current international practices for preoperative preparation, training, and intraoperative key steps of C-RLS. Prospective validation of the key steps would be useful for correlating clinical outcomes with current practice.