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PC Giulianotti, MD, FACS

Robotic Liver Surgery. PC Giulianotti, MD, FACS. Professor and Chief Division of General, Minimally Invasive and Robotic Surgery University of Illinois Medical Center at Chicago. Robotic Surgery. The UIC program. Robotic Surgery. The UIC program. Robotic Liver Surgery. Backgrounds.

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PC Giulianotti, MD, FACS

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  1. Robotic Liver Surgery PC Giulianotti, MD, FACS Professor and Chief Division of General, Minimally Invasive and Robotic Surgery University of Illinois Medical Center at Chicago

  2. Robotic Surgery The UIC program

  3. Robotic Surgery The UIC program

  4. Robotic Liver Surgery Backgrounds • Lesion size:No limits. Exclusion of sub-capsular extension and major vessels infiltration. • Location:All the segments except segment I. (Posterior segment when a major hepatectomy is required). • 3. Extension:Left lateral Sectionectomy, Segmentectomy, • Bisegmentectomy, Major Hepatectomies, Extended Hepatectomy • 4. Pathology:Benign lesions (selected), • Malignant lesions: -HCC • - CRLM/ NCRLM • - Hilar malignancy • 5. Pediatric and Adult Living donor:limited experience • 6. Contraindications:Subcapsular extension, Invasion of Major Hepatic Vessels, (Portal vein resection).

  5. Laparoscopic Liver Surgery Backgrounds 1992 First laparoscopic liver resection Gagner et al. Surg Endosc 1992; 6: 99. 1996 First anatomic laparoscopic liver resection Azagra et al. Surg Endosc 1996; 10: 758-761. • 1997 • First laparoscopic major liver resection • Huscher et al. J R Coll Surg Edinb 1997; 42: 219-225.

  6. Laparoscopic Liver Surgery Consensus • Currently acceptable indications: solitary lesions, 5 cm or less, located in liver segments 2 to 6 • Major liver resections should be reserved for experienced surgeons • Conversion should not be considered as a failure • Utilization of a hand assist or hybrid technique may be faster and safer • Laparoscopic liver surgery has not been tested by controlled trials for efficacy or safety • A prospective randomized trial appears to be logistically prohibitive • An international registry should be initiated to document the role and • safety of laparoscopic liver resection.

  7. Laparoscopic Liver Surgery Limitations ? • Surgical skills • Previous laparotomy • Tools and instruments (suturing, retraction…) • Location of the lesions (posterior segments) • Extension of resection (major resections) • Complex resections and reconstruction (hilar cholangiocarcinoma)

  8. Robotic Liver Surgery RoboticLiver Surgery: background Backgrounds • In the current literature, only few small robotic series • Good clinical results • Robotic facilitate liver resection • Especially for procedures that require a small operating field • Left lateral sectionectomy is the first step in the learning curve Giulianotti PC et al. Arch Surg 2003;138:777-84. Patriti A et al. J Hepatobiliary Pancreat Surg 2009;16:450-7. Tomulescu V et al. Chirurgia (Bucur) 2009;104:141-50. Vasile S et al. Chirurgia (Bucur) 2008;103:401-5. Choi SB et al. Yonsei Med J 2008;49:632-8.

  9. Robotic Liver Surgery RoboticLiver Surgery: background Backgrounds Surgery 2010; June 4

  10. Robotic Liver Surgery Our technique Right Resections Or setup • Assistant surgeons at patient side: • Suctioning • Stapling • Clipping • Changing instruments • Laparoscopic Ultrasonography Left Resections

  11. Robotic Liver Surgery Our technique OR setup Right Resections Trocar Positioning REVERSE TRENDELEMBURG Patient Positioning

  12. Robotic Liver Surgery Our technique Trocar Positioning 4 2 3 1 4 3 2 1 Right Resections Left Resections

  13. Robotic Liver Surgery Our technique Intraoperative ultrasound

  14. Robotic Liver Surgery Our technique Standardized technique

  15. Robotic Liver Surgery Robotic Liver Surgery Standardized Technique: 3 steps 1st step: Hilum dissection 2nd step: Dissection of the vena cava 3rd step: Parenchymal transection

  16. Robotic Liver Surgery Robotic Liver Surgery Robotic Liver Surgery Phase 1: Hilum dissection • ADVANTAGES • Retraction and exposure • (4th arm) • Stability • Magnification • Microsurgical capabilities Left Right

  17. Robotic Liver Surgery Robotic Liver Surgery Robotic Liver Surgery Phase 2: Hepatocaval dissection • ADVANTAGES • Retraction and lifting of the • liver (4th arm) • Stability • Magnification • Ability to work in a very • deep and narrow field

  18. Robotic Liver Surgery Robotic Liver Surgery Robotic Liver Surgery Phase 3: Parenchymal transection • ADVANTAGES • Retraction (stay sutures / 4th arm) • Stability • Magnification • Precise energy delivery • to tissue (Harmonic) • Ability to microsuture Cortical and Intermediate Aspect Deep Part (stapler)

  19. Robotic Liver Surgery Phase 3: Parenchymal transection Bleeding-Management

  20. Robotic Liver Surgery Robotic Liver Surgery Our experience Robotic Liver Surgery: our experience 100 Robotic Liver resections 49 males and 51 females Mean age 56.2 yrs (range 20 – 84) Hepatic lesions localization 22 II 18 6 VII VIII 1 III 14 IV VI V 2 10 4 23

  21. Robotic Liver Surgery Robotic Liver Surgery Robotic Liver Surgery: personal experience Our experience Robotic Liver Surgery: our experience Major Hepatectomies: 38 Right hepatectomy 29 pts Left hepatectomy 7 pts Right trisectionectomy + Biliary reconstruction 2 pts Minor Resections: 62 Segmentectomy 19 pts Bisegmentectomy 18 pts Left lateral sectionectomy 11 pts Non Anatomical 14 pts Adapted from Giulianotti PC et al. Surgery 2010; Jun 4.

  22. Robotic Liver Surgery Robotic Liver Surgery Robotic Liver Surgery: personal experience Robotic Liver Surgery: personal experience Our experience Robotic Liver Surgery: our experience RESULTS • MAJOR HEPATECTOMIES • Mean Operative time: 377.2 min (175-840) • MINOR RESECTIONS • Mean Operative time: 221.3 min (45-579) Mortality: NO MORTALITY Conversion: 11% Transfusions: 10% (majority cirrhotic patients) Only one Pringle maneuver Morbidity: 16% Length of stay: 7 days (5 days in US)

  23. Robotic Liver Surgery Robotic Liver Surgery Robotic Liver Surgery: personal experience Robotic Liver Surgery: personal experience Our experience Robotic Liver Surgery: our experience US experience: follow up Median follow up: 16 months (1-31)

  24. Robotic Liver Surgery Robotic Liver Surgery Robotic Liver Surgery: personal experience Robotic Liver Surgery: personal experience Robotic Liver Surgery: our experience To expand the limits • Extended hepatectomy with biliary reconstruction • Preliminary experience with vascular resection • Preliminary experience with posterior lesions

  25. Robotic Liver Surgery Robotic Liver Surgery Robotic Liver Surgery: personal experience Robotic Liver Surgery: personal experience Robotic Liver Surgery: our experience To expand the limits

  26. Conclusions • Robotic surgery is safe and feasible in experienced hands • The technical abilities of the robotic system might improve the critical steps of minimally invasive major liver resections • Only robotics make feasible complex minimally invasive liver resections • Robotic surgery may expand the indications for minimally invasive liver surgery

  27. Conclusions • For oncology, robotic surgery is one of the tool to extend the limit of minimally invasive surgery in the field of liver resections • Probably achieves the same oncological results as open approach • Achieves low morbidity and mortality rate • Reopens the possibilities of minimally invasive surgery

  28. The Robotic Training Lab The Bruno and Tony Pasquinelli Lab Procedures performed at UIC and offered for training include: • Splenectomy • Total gastrectomy • Lung lobectomy • Colorectal surgery • Thyroidectomy • Adrenalectomy • Esophagectomy • Major hepatectomies • CBD Procedures • Whipple

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