Background: Robotic procedures are an integral part of modern liver surgery. However, the advantages of a robotic approach in comparison to the conventional laparoscopic approach are the subject of controversial debate. The aim of this systematic review and meta-analysis is to compare robotic and laparoscopic liver resection with particular attention to the resection margin status in malignant cases. Methods: A systematic literature search was performed using PubMed and Cochrane Library in accordance with the PRISMA guidelines. Only studies comparing robotic and laparoscopic liver resections were considered for this meta-analysis. Furthermore, the rate of the positive resection margin or R0 rate in malignant cases had to be clearly identifiable. We used fixed or random effects models according to heterogeneity. Results: Fourteen studies with a total number of 1530 cases were included in qualitative and quantitative synthesis. Malignancies were identified in 71.1% (n = 1088) of these cases. These included hepatocellular carcinoma, cholangiocarcinoma, colorectal liver metastases and other malignancies of the liver. Positive resection margins were noted in 24 cases (5.3%) in the robotic group and in 54 cases (8.6%) in the laparoscopic group (OR = 0.71; 95% CI (0.42–1.18); p = 0.18). Tumor size was significantly larger in the robotic group (MD = 6.92; 95% CI (2.93–10.91); p = 0.0007). The operation time was significantly longer in the robotic procedure (MD = 28.12; 95% CI (3.66–52.57); p = 0.02). There were no significant differences between the robotic and laparoscopic approaches regarding the intra-operative blood loss, length of hospital stay, overall and severe complications and conversion rate. Conclusion: Our meta-analysis showed no significant difference between the robotic and laparoscopic procedures regarding the resection margin status. Tumor size was significantly larger in the robotic group. However, randomized controlled trials with long-term follow-up are needed to demonstrate the benefits of robotics in liver surgery.

Background: The implementation of robotics in liver surgery offers several advantages compared to conventional open and laparoscopic techniques. One major advantage is the enhanced degree of freedom at the tip of the robotic tools compared to laparoscopic instruments. This enables excellent vessel control during inflow and outflow dissection of the liver. Parenchymal transection remains the most challenging part during robotic liver resection because currently available robotic instruments for parenchymal transection have several limitations and there is no standardized technique as of yet. We established a new strategy and share our experience. Methods: We present a novel technique for the transection of liver parenchyma during robotic surgery, using three devices (3D) simultaneously: monopolar scissors and bipolar Maryland forceps of the robot and laparoscopic-guided waterjet. We collected the perioperative data of twenty-eight patients who underwent this procedure for minor and major liver resections between February 2019 and December 2020 from the Magdeburg Registry of minimally invasive liver surgery (MD-MILS). Results: Twenty-eight patients underwent robotic-assisted 3D parenchyma dissection within the investigation period. Twelve cases of major and sixteen cases of minor hepatectomy for malignant and non-malignant cases were performed. Operative time for major liver resections (≥ 3 liver segments) was 381.7 (SD 80.6) min vs. 252.0 (70.4) min for minor resections (p < 0.01). Intraoperative measured blood loss was 495.8 (SD 508.8) ml for major and 256.3 (170.2) ml for minor liver resections (p = 0.090). The mean postoperative stay was 13.3 (SD 11.1) days for all cases. Liver surgery-related morbidity was 10.7%, no mortalities occurred. We achieved an R0 resection in all malignant cases. Conclusions: The 3D technique for parenchyma dissection in robotic liver surgery is a safe and feasible procedure. This novel method offers an advanced locally controlled preparation of intrahepatic vessels and bile ducts. The combination of precise extrahepatic vessel handling with the 3D technique of parenchyma dissection is a fundamental step forward to the standardization of robotic liver surgery for teaching purposing and the wider adoption of robotic hepatectomy into routine patient care.

Robotic-assisted procedures gain increasing acceptance for daily surgical routine. However, structured training programs are designed for surgeons with high expertise. Hence, a comprehensive training curriculum was established to ensure a basic competence in robotic abdominal surgery for young surgeons during their residency. The aim of the current work is to propose a feasible and effective training concept. The development process of this training curriculum is based on a comprehensive literature review which led to the concept of “robotic curriculum for young surgeons” (RoCS). It was implemented in the daily routine of a German university hospital starting in 2020. The robotic assessment questionnaire (RAQ) was used for electronic data collection. After the initial phase adjustments, it led to an improvement of the initial version of the curriculum. RoCS is a multimodal training program containing basic training through assistance at the operation table during robotic-assisted operations and basic console training. Key elements are the robotic team time-out (rTTO), perioperative process standardization including feasible personnel scheduling and useful procedure clustering into organ systems, procedural steps and procedural step complexity. Evaluation of standardized communication, performance assessment, patient factors and individual overall workload using NASA Task Load Index is realizable. Flexibility and adaptability to internal organization processes of surgical departments are the main advantages of the concept. RoCS is a strong training tool to meet the specific needs of young surgeons and evaluate their learning success of robotic procedural training. Furthermore, comparison within the different robotic systems should be considered. Further studies are needed to validate a multicenter concept design.

Robotic vs. laparoscopic liver surgery: what are the advantages of the robot? Roland S. Croner, Andrew A. Gumbs, Aristotelis Perrakis, Mihailo Andric, Jessica Stockheim, Eric Lorenz, Joerg Arend, Mareike Franz, Mirhasan Rahimli

The “Robotic Curriculum for young Surgeons” (RoCS) was launched 03/2020 to address the increasing importance of robotics in surgical training. It aims to provide residents with foundational robotic skills by involving them early in their training. This study evaluated the impact of RoCS’ integration into clinical routine on patient outcomes. Two cohorts were compared regarding the implementation of RoCS: Cohort 1 (before RoCS) included all robot-assisted procedures between 2017 and 03/2020 (n = 174 adults) retrospectively; Cohort 2 (after RoCS) included all adults (n = 177) who underwent robotic procedures between 03/2020 and 2021 prospectively. Statistical analysis covered demographics, perioperative parameters, and follow-up data, including mortality and morbidity. Subgroup analysis for both cohorts was organ-related (upper gastrointestinal tract (UGI), colorectal (CR), hepatopancreaticobiliary system (HPB)). Sixteen procedures were excluded due to heterogeneity. In-hospital, 30-, 90-day morbidity and mortality showed no significant differences between both cohorts, including organ-related subgroups. For UGI, no significant intraoperative parameter changes were observed. Surgery duration decreased significantly in CR and HPB procedures (p = 0.018 and p < 0.001). Estimated blood loss significantly decreased for CR operations (p = 0.001). The conversion rate decreased for HPB operations (p = 0.005). Length of hospitalization decreased for CR (p = 0.015) and HPB (p = 0.006) procedures. Oncologic quality, measured by histopathologic R0-resections, showed no significant changes. RoCS can be safely integrated into clinical practice without compromising patient safety or oncologic quality. It serves as an effective training pathway to guide robotic novices through their first steps in robotic surgery, offering promising potential for skill acquisition and career advancement.

Zusammenfassung Einleitung Der Einsatz roboterassistierter Operationen verzeichnet in der Viszeralchirurgie gegenwärtig einen stetigen Zuwachs. Im Jahr 2020 hat die COVID-19-Pandemie den klinischen und chirurgischen Alltag unerwartet wesentlich verändert. Wir haben in einer Umfrage den Status der roboterassistierten Viszeralchirurgie in Deutschland sowie die gegenwärtigen Ausbildungskonzepte evaluiert und deren Veränderungen unter dem Einfluss der COVID-19-Pandemie untersucht. Material und Methoden In einer umfangreichen Recherche wurden 89 Kliniken identifiziert, welche ein Robotersystem für die Viszeralchirurgie 2020 einsetzten. Diese Kliniken wurden über eine webbasierte anonyme Umfrage mit 35 Fragen dreimal kontaktiert. Die Fragen bezogen sich auf die Einsatzgebiete eines Operationsroboters in der Viszeralchirurgie, die dazugehörige klinische Ausbildung und den Einfluss der COVID-19-Pandemie auf das bestehende Programm. Ergebnisse Von den angeschriebenen Kliniken haben 22 (24,7%) eine Rückmeldung gegeben. Hiervon waren 17 (19,1%) Fragebögen auswertbar. Es beteiligten sich 58,8% Universitätsklinika, 17,6% Maximalversorger und 23,5% Schwerpunktkrankenhäuser an der Studie. Der Operationsroboter wurde am oberen Gastrointestinaltrakt (OGIT; 88,2%), am hepatopankreatikobiliären System (HPB; 82,4%) und im kolorektalen Bereich (KRK; 94,1%) sowie bei der Hernienversorgung (35,3%) eingesetzt. Der relative Anteil robotischer Eingriffe am operierten Gesamtkollektiv lag dabei zwischen 0,3% und 15,4%. Die Konversionsraten für 2020 lag im Mittel bei 4,6 ± 3,2%. Die Operationsroboter wurden zum Großteil im interdisziplinären Setting wechselweise mit anderen chirurgischen Disziplinen (82,4%) genutzt. Zu Lehrzwecken stand in sieben Kliniken (41,2%) eine zweite Konsole zur Verfügung. Die Ausbildungsstrukturen waren sehr heterogen und nur 13,2 ± 6,5% der Chirurg*innen pro Klinik waren in das Roboterprogramm involviert. In 82,4% existierten feste Teams, die sich aus Ober‑, Fach- und Assistenzärzt*innen zusammensetzen und in 76,5% wurden Ärzt*innen und Pflegepersonal über klinikinterne Ausbildungsprogramme geschult. Die COVID-19-Pandemie hatte einen Fallzahlrückgang robotischer Eingriffe im Vergleich zu 2019 bei 70% der Kliniken vor allem im zweiten Jahresquartal 2020 (64,7%) zur Folge. Dies wurde auf Personalmangel nichtchirurgischer Disziplinen (Anästhesie 35,3%, OP-Pflege 35,3%, Intensivmedizin 17,6%), interne Regularien (58,8%) und begrenzte Intensiv- oder Überwachungskapazitäten (47,1%) zurückgeführt. Die COVID-19-Pandemie führte in der robotischen Ausbildung teilweise bei der Assistenz am OP-Tisch (23,5%) und der Assistenz an der zweiten Konsole (42,9%) zu einem kompletten Ausbildungsstopp. Ausschlaggebend für diese Entwicklung war überwiegend der Rückgang der Operationszahlen. Schlussfolgerung Die Robotik wird mittlerweile in einem breiten Spektrum der Viszeralchirurgie an Kliniken mit unterschiedlichen Versorgungsschwerpunkten in Deutschland eingesetzt. Der relative Anteil der Eingriffe am Gesamtspektrum ist allerdings noch gering. Roboterassistierte Eingriffe sind expertenfokussiert und es bestehen sehr heterogene Ausbildungskonzepte. Ein Lernerfolg mit konstanten und niedrigen Konversionsraten ist nach wenigen Jahren mit zunehmender Erfahrung zu erkennen. Die COVID-19-Pandemie hatte insgesamt einen negativen Einfluss auf die robotischen OP-Fallzahlen und die damit verbundenen Ausbildungsmöglichkeiten bei freien chirurgischen Personalressourcen. Hier ist eine kreative Gestaltung optimierter Ausbildungsmodalitäten erforderlich.