Authors: Liu Rong, Zhang Xiuping, Yu Zetao
Source: Chinese Journal of General Surgery, 2024, 39(1)
summary
As the development trend of minimally invasive surgery, robotic surgery is currently widely used in clinical practice, especially in hepatobiliary and pancreatic surgery, because of its better surgical field effect, more flexible robotic arm, and more stable for fine operation. This article summarizes the research status at home and abroad and reviews the current research progress and clinical effects of robots in pancreatic surgery, liver surgery and biliary surgery based on the author's own experience, and looks forward to the future development trend of robotic surgery.
Since the da Vinci robotic system was approved for clinical use in 2000, surgery has entered the era of robotic exploration. In recent years, robot-assisted surgical systems have developed rapidly and are widely used in many disciplines such as general surgery, thoracic surgery, and gynecology, and more than 70 countries have put the da Vinci robotic system into use. Compared with traditional surgical methods, the da Vinci robotic system has a high-definition three-dimensional field of view, and a flexible robotic arm can effectively filter arm tremors and achieve the purpose of fine operation in a small space [1, 2]. Due to the deep surgical site, insufficient space, complex anatomy, and high surgical precision requirements of hepatobiliary and pancreatic surgery, it has a wider demand for robot applications. Since 2012, the author's team has completed nearly 8 000 cases of robotic hepatobiliary and pancreatic surgery.
1. Research progress in robotic pancreatic surgery
（一）机器人胰十二指肠切除术（robotic pancreaticoduodenectomy，RPD）的研究进展
Pancreaticoduodenectomy is one of the most complex surgeries in hepatobiliary and pancreatic surgery, and before the advent of RPD, open pancreaticoduodenectomy (OPD) and laparoscopic pancreaticoduodenectomy (LPD) were the main surgical modalities for this operation. Postoperative hemorrhage and other complications are the main reasons for the length of postoperative hospital stay and short-term rehospitalization. RPD was first reported in 2003 by Giulianotti et al. [3]. In order to evaluate the advantages and disadvantages of RPD versus conventional OPD, our team conducted a multicenter propensity-matched analysis and found that although there was no significant difference between RPD and OPD in the occurrence of postoperative complications, RPD had less intraoperative bleeding and shorter postoperative hospital stay [4]. This is similar to the results of Shi et al. [5], which showed that RPD has a high safety profile and feasibility. For RPD and LPD, which are also representative of minimally invasive surgery, Khachfe et al. [6] compared the short-term postoperative outcomes of the two postoperative procedures, and concluded that the overall complications and serious complications of RPD were significantly lower than those of LPD, and the short-term postoperative outcomes were better. Surgery for RPD remains safe and feasible for obese and older patients, and obesity and age are not contraindications to RPD surgery [7, 8]. Because the pancreas is located retroperitoneally and the surrounding anatomy is complex, pancreaticoduodenectomy is difficult. In order to reduce the difficulty of surgery and facilitate the uncinate process to be anastomosed with the gastrointestinal tract, the author innovatively proposed the concept of "L-foramen and R-foramen", and pioneered the operation of LR-style RPD, which reduced the occurrence of postoperative bleeding and delayed gastric emptying [9]. On the basis of the L-hole, the modified pancreatic-intestinal anastomosis, single-needle full-thickness pancreatic-intestinal anastomosis ("301" pancreatic-intestinal anastomosis), also greatly shortens the time of pancreatic-intestinal anastomosis [10, 11]. In order to increase the resectability of pancreatic tumors and reduce intraoperative bleeding, some scholars have proposed strategies of "arterial priority" and "uncinate process first" [12, 13]. However, due to the complex anatomy, large vascular variability, and dense branches of the pancreas, especially the head of the pancreas, it is difficult to achieve R0 resection. As one of the most complex surgeries in hepatobiliary and pancreatic surgery, the application of robots greatly reduces the trauma caused to patients and shortens the wound healing time, which has great advantages.
(2) Research progress of robotic distal pancreatectomy
In addition to RPD, robots are also widely used in partial pancreatic resection, pancreatic tail + splenectomy, etc. Lof et al. [15] included a total of 402 patients with robotic distal pancreatectomy (RDP) and 402 laparoscopic distal pancreatectomy (LDP) patients in a multicenter study of the International Propensity Match Score. The spleen-sparing rate and rehospitalization rate were lower than those in the LDP group. For benign tumors of the tail of the pancreas, distal pancreatectomy with preservation of the spleen is the most ideal surgical method, and sparing the spleen can effectively avoid complications such as platelet elevation and dangerous infection caused by splenectomy. To explore the advantages and disadvantages of robotic and laparoscopic methods in sparing the spleen during distal pancreatic resection, Rompianesi et al. [16] pooled 11 studies for meta-analysis and found that robotic surgery was superior to laparoscopic surgery in terms of spleen-sparing rate, intraoperative blood loss, and hospital stay. For pancreatic caudal cancer, surgery is still the main treatment modality, but its prognosis is poor, so the author proposed the "circumcisive anterograde modular pancreaticosplenectomy" on the basis of radical anterograde modular pancreaticosplenectomy and circumvascular vascular techniques, which has good surgical effect and clinical benefits, and gives full play to the advantages of robotic surgery [17, 18]. In surgery involving pancreatic injury, if the main pancreatic duct is damaged, the surgeon will generally perform anastomosis between the pancreatic duct and the digestive tract, which not only increases the surgical injury of the patient, but also makes the pancreatic leakage more serious because trypsin is more likely to bind to enterokinase. Therefore, the author proposed the concept of "pancreatic duct repair surgery", which mainly includes main pancreatic duct repair, pancreatic end-to-end anastomosis, and local resection of branched intraductal papillary myxoma [19, 20], which has confirmed the safety and feasibility of robotic pancreatic duct repair in practice, and this procedure is more in line with human physiological structure and retains the functions of pancreatic endocrine and exocrine to the greatest extent [21]. In addition, in order to reduce surgical trauma, our team performed a single-port robotic pancreatectomy for the first time, confirming the feasibility of single-port robotic pancreatic surgery [22]. Subsequently, the authors have accumulated some cases of single-port robotic pancreatic surgery, which has laid the foundation for the further development of this procedure [23]. In terms of safety during the learning period of robotic surgery, Klompmaker et al. [24] concluded that as long as standardized training is present, the safety of early RDP is not affected and the length of hospital stay can be reduced immediately. In our study, we also found no significant differences in the learning, plateau, and maturation stages of robotic radical anterograde modular pancreaticosplenectomy in terms of morbidity and mortality [25]. Therefore, RDP is safe and feasible even in the early learning stage, which is of great significance for the early development of robotic surgery.
2. Research progress in robotic liver surgery
In terms of liver surgery, robotic surgery has also been reported in recent years, and surgical methods such as anatomic liver resection, left hepatic resection, right hepatic resection, and liver transplantation living-donor resection have been involved. Similar to pancreatic surgery, robotic liver surgery also has good short-term clinical benefits, and the authors found that robotic liver resection has less blood loss and lower laparotomy rate than laparoscopic liver resection, and significantly reduces the incidence of postoperative complications and postoperative hospital stay in patients with cirrhosis [26]. For example, in Chong et al. [27], a propensity score matching of 989 patients found that compared with laparoscopic right hemihepatectomy, robotic right hemihepatectomy had the advantages of shorter postoperative hospital stay and lower laparotomy rate. This was further validated in the study of Cai et al. [28].
As a commonly used fluorescent display agent in liver resection surgery, indocyanine green still has a stable role in robotic liver resection, and the "four-zone three-phase" fluorescence imaging method proposed by our team can clearly visualize liver tumors through real-time navigation, which is helpful for surgical resection [29]. Robots have a good effect on some complex surgeries, Xiao Yuanhong et al. [30] reported a successful case of a 6-year-old child robot's right liver hemangioma; Kim et al. [31] also found that in liver transplantation living-donor resection surgery, robots have advantages over laparoscopy, with less trauma and less bleeding. In addition, after thorough preparation and evaluation, the authors' team also successfully completed the left lateral hepatectomy of a single-port robot, providing safe and feasible technical guidance for single-port robotic liver resection [32].
In terms of the long-term survival benefit of robotic surgery, Zhu et al. [33] conducted a prospective study on patients with BCLC stage 0 and stage A hepatocellular carcinoma and found that robotic or laparoscopic hepatectomy had no effect on the long-term survival outcomes of patients. The authors believe that the long-term benefit of patients is mainly due to the R0 resection of the tumor, which reduces the possibility of metastasis. At present, the most widely used anatomic liver resection in clinical practice is mainly based on the Couinaud segmentation method, which treats each segment as an independent unit with an inflow and outflow channel. However, based on a series of clinical phenomena, the author found that each liver segment is not independent of each other, but can affect each other, and the intrahepatic blood vessels and liver parenchyma are like rivers irrigating the soil, so as to propose the "liver basin theory" [34]. On this basis, the authors further proposed the "target resection technique" of the liver, and the author believes that according to the watershed theory, the resection target division of the area where the tumor may infiltrate and metastasize may be carried out, and then surgical resection may reduce the recurrence of the tumor and improve the long-term prognosis of patients [35]. The vigorous development of robotic surgery will be more conducive to the precise resection of the delineated target, and its effectiveness needs to be further studied and explored.
3. Research progress in robotic biliary surgery
(1) Research progress of robotic cholangiocarcinoma surgery
In recent years, robotic biliary surgery has also attracted much attention, and related studies such as robotic radical hilar cholangiocarcinoma and gallbladder cancer radical resection have been reported from time to time [36, 37]. Biliary tract surgery is particularly careful in anatomy, especially for hilar cholangiocarcinoma, which has complex anatomy and higher precision requirements, and robotic surgery can better meet this demand. The authors' team summarized the data of 34 patients who underwent robotic hilar cholangiocarcinoma radical resection from 2016 to 2017, and there were no perioperative deaths and secondary surgeries, so they concluded that robotic hilar cholangiocarcinoma surgery was safe and feasible [38]. Tee et al. [36] also reported a successful case of robotic hilar cholangiocarcinoma. Taj Mahal hepatectomy is an important surgical modality for the treatment of hilar cholangiocarcinoma, and our team used robotic Taj hepatectomy for the first time to treat a patient with complex hilar cholangiocarcinoma, confirming the feasibility of this procedure in robotic surgery [39]. Although there has been some progress in the surgical research of robotic hilar cholangiocarcinoma, there is still a lack of large-scale data support, and its safety and efficacy may need to be verified by further large-sample prospective studies.
(2) Research progress of robotic gallbladder disease surgery
In the treatment of gallbladder cancer, Goel et al. [37] found that robotic radical gallbladder cancer surgery has less intraoperative bleeding, shorter hospital stay, and fewer postoperative complications than open radical gallbladder cancer surgery, and robotic surgery is safe and feasible. Similarly, Cho et al. [40] also found that although there was no significant difference in the long-term prognosis between robotic gallbladder enlargement and laparotomy compared with laparotomy in 125 cases of propensity score matching, the short-term outcome was better and the postoperative pain was less, which was conducive to rapid postoperative recovery. At present, single-port laparoscopic cholecystectomy has been widely used in clinical practice, and good results have been achieved in terms of safety and minimally invasiveness. Studies comparing robotic cholecystectomy with laparoscopic cholecystectomy have found no significant difference in safety and perioperative outcomes, with robotic cholecystectomy being associated with longer operative times due to more preparation time [41]. In view of the higher price of robotic surgery, it does not have obvious advantages in conventional cholecystectomy, but whether it has certain advantages in the acute stage of cholecystitis can be further explored.
Fourth, summary and outlook
In short, robotic surgery has the advantages of short operation time, less bleeding and short hospital stay on the basis of ensuring safety and effectiveness, so it occupies an increasingly important position in hepatobiliary and pancreatic surgery, and is the overall development trend of hepatobiliary and pancreatic surgery. On this basis, single-port robotic surgery is constantly being explored, which is more in line with the principles of trauma minimization and patient benefit maximization. At present, the authors' team has achieved good results in single-port robotic surgery, which has laid the foundation for its next development [22, 23,32]. In addition, with the support of 5G communication technology, the author has completed the world's first remote surgical test and the first multi-point collaborative remote multidisciplinary robotic animal experiment. At present, a number of ultra-remote surgeries have been carried out in the world, and good results have been achieved. The combination of robotic surgery and 5G communication technology may make medical resources no longer limited by geography. Another development direction of robotic surgery may tend to be intelligent and automated, combining artificial intelligence with surgery, on the one hand, it may integrate multidisciplinary technology to promote the development of multidisciplinary surgery, and on the other hand, it may make surgery change to the direction of automation. Although robotic surgery also has disadvantages such as long start-up preparation time and high surgical cost, these shortcomings can be eliminated by further development of robotic systems. Therefore, the future development prospects of robotic surgery are very broad, and the author is very much looking forward to it playing a more important role in clinical practice.
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