Application of da Vinci robot and laparoscopy on repeat hepatocellular carcinoma.

Background: Repeat laparoscopic liver resection has been used safely and effectively on hepatocellular carcinoma (HCC). However, few studies have been performed on repeat HCC surgery by a da Vinci robot. This study aims to evaluate the outcomes of the patients with repeat HCC treated using a da Vinci robot or laparoscopic system at a single centre.
Methods: All of the patients with repeat HCC treated using a da Vinci robotic or laparoscopic system between April 2017 and April 2020 were included in this retrospective study.
Results: There were 24 patients with a mean age of 56 years who underwent da Vinci robotic or laparoscopic surgery for treatment of repeat HCC who were included in this study. The operations lasted 152 ± 25 min and 142 ± 34 min. The average intraoperative blood loss was 284 ± 89 ml and 251 ± 92 ml. The average hospitalisation stay lasted 9 ± 2 days and 9 ± 3 days. The rates at which surgeons switched to open surgery were 9% and 23%. No serious perioperative or post-operative complications were encountered.
Conclusion: Da Vinci robots can provide a precise dissection of the tissue under a perfect view. It is a technically feasible procedure for less rates at which surgeons switched to open surgery on repeat HCC.

INTRODUCTION

Hepatocellular carcinoma (HCC) is a common malignant tumour. Liver resection (LR) has become the treatment of choice.[123] Patients whose recurrent HCC (rHCC) is treated by repeat LR enjoy a relatively good prognosis.[45] The treatment of rHCC is typically performed through the open resection, which creates serve incision scars and can cause intraperitoneal adhesion, which render it more difficult to perform any subsequent surgical resection. Laparoscopy for rHCC has been shown to have several feasibility and safety advantages,[6789] but few studies have explored rHCC surgery by a da Vinci robot.

Da Vinci robots have seen increasing use in gastrointestinal surgery, urology and gynaecological surgery because they have many advantages such as three-dimensional (3D) vision and visual magnification.[101112] However, there have been few reports about the performance of da Vinci robots in rHCC surgery. We here aimed to investigate the feasibility and efficiency of the da Vinci robot in rHCC surgery.

METHODS

Patients

Patients undergoing rHCC surgery who were treated using da Vinci robots or laparoscopic systems at the First Affiliated Hospital of Guangxi Medical University between April 2017 and April 2020 were enrolled in this retrospective study, including 12 men and 12 women, aged 28–72 years, mean age 56 years. The 24 cases had undergone at least one surgery on upper abdominal preoperatively. These are shown in Tables 1 and 2.

Table 1

Information of patient of robot assisted on recurrent hepatocellular carcinoma

Case	Gender	Age (years)	The operative time (min)	The blood loss (ml)	Hospital time (days)	Turned to open surgery	Serious complication
1	Female	65	160	300	12	N	N
2	Male	45	150	380	9	N	N
3	Female	61	180	320	11	N	N
4	Male	55	130	100	7	N	N
5	Female	60	130	180	5	N	N
6	Female	64	120	350	9	N	N
7	Female	58	160	250	9	N	N
8	Male	38	190	360	11	N	N
9	Female	68	180	300	10	N	N
10	Female	70	150	380	12	Y	N
11	Male	47	120	180	7	N	N

Table 2

Information of patients of laparoscopic repeat liver resection for recurrent hepatocellular carcinoma

Case	Gender	Age (years)	The operative time (min)	The blood loss (ml)	Hospital time (days)	Turned to open surgery	Serious operation complication
1	Male	47	130	180	7	N	N
2	Female	42	110	280	8	N	N
3	Male	41	180	300	12	Y	N
4	Male	56	120	120	6	N	N
5	Male	65	110	150	6	N	N
6	Female	64	180	350	10	N	N
7	Female	57	120	200	9	N	N
8	Male	28	190	360	12	Y	N
9	Male	68	200	360	13	Y	N
10	Female	72	160	350	12	N	N
11	Male	45	120	300	10	N	N
12	Male	53	110	160	7	N	N
13	Female	60	120	150	6	N	N

The inclusion criteria were as follows: (1) history of upper abdominal surgery, (2) repeat HCC surgery and (3) surgery performed using either a da Vinci robot or laparoscopic system. Patients with histories of the surgeries than upper abdominal were excluded.

The study was approved by the Ethics Committee of the First Affiliated Hospital of Guangxi Medical University. All of the patients provided written informed consent.

Surgical procedure of robot assisted on recurrent hepatocellular carcinoma surgery

Clinical assessment, including a thorough history, physical examination, routine blood tests, alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA), computerised tomography (CT) of chest and abdomen and magnetic resonance imaging (MRI) of the abdomen, was completed for all of the patients before robotic surgery.

For surgery, the patients were placed in a supine position, with the head higher than the feet lower, with their legs spread apart. The positions of the ports were as follows: first, a small incision (12 mm in length, it can be an auxiliary hole or a lens hole of the da Vinci robot) was made under direct vision, as far from any pre-operative incision adhesions preoperatively as possible. A 12-mm trocar was inserted and pneumoperitoneum was established. Pressure was maintained at 13 mmHg. Next, two 12-mm or 5-mm ports were set at a site with no or few adhesions. Third, the other ports, including assistant and da Vinci robot ports, were set under direct lens vision. All da Vinci robot ports were kept as far apart as possible to prevent interference between the da Vinci robot arms. The ports were placed as shown in Figures 1 and 2. Before the surgical procedure, the surgeon and assistant moved the forceps to confirm whether the operations could be performed properly without interference among the da Vinci robot arms. Then, the da Vinci robot was manipulated. Adhesions on the abdominal wall need to be separated under direct lens vision. Most of the surgical procedures were performed by the surgeon using da Vinci robot. The assistant increases visibility by using forceps and manipulating an incision coagulator. Last, repeat hepatobiliary surgery was completed by da Vinci robot. The parts of surgical procedures were carried out, as shown in Figures 3 and 4.

Figure 1

Port placement in the supine and position of head higher and foot lower

Figure 2

Port placement in the supine and position of head higher and foot lower (after docking)

Figure 3

Separation of abdominal wall adhesion in recurrent hepatocellular carcinoma by da Vinci robot

Figure 4

Tumour incision in recurrent hepatocellular carcinoma surgery by da Vinci robot

Surgical procedure of laparoscopic system for rHCC surgery[7] is shown in Figures 5 and 6.

Figure 5

Separation of abdominal wall adhesion in recurrent hepatocellular carcinoma surgery by laparoscopic system

Figure 6

Tumour incision in recurrent hepatocellular carcinoma surgery by laparoscopic system

Outcome assessment and post-surgery follow-up

Data on peri-operative outcomes, operation time, blood loss, hospitalisation, complications and turned to open surgery rate were recorded. The patients were to return routinely for examination. Evaluations included a thorough history, physical examination, routine blood tests, AFP and CEA, CT of the chest and abdomen and MRI of the abdomen. The mean follow-up time was 18 months. At the last follow-up, two patients died because of tumour recurrence, the other patients were surviving and had no serve complications.

Statistical methods

All relevant data were statistically analysed using IBM SPSS 13.0 (International Business Machines Corporation, New York state, USA) software. Different groups of data were analysed with t-test or Chi-square test statistical methods. The significance level was set as α = 0.05. When P ≤ 0.05, the difference was considered statistically significant.

RESULTS

There were 11 patients with rHCC who successfully underwent operation using da Vinci robots and 13 were successfully treated by laparoscopic systems. Adhesions on the abdominal wall were dissected under direct lens vision before docking in 9 cases. Then, da Vinci robot ports were docked and the procedures of rHCC surgery were performed. In the other cases, the abdominal wall adhesions did not need to be separated before docking and da Vinci robot ports were docked directly. Then, adhesions were separated and surgery was carried out in the da Vinci view. The incision scars were small, aesthetically acceptable and healed well after the operation, as shown in Figure 7. No severe perioperative complications were observed. In patients treated using the da Vinci robot, the average duration of surgery was 152 ± 25 min, the average intraoperative blood loss was 284 ± 89 ml and the average post-operative hospital stay was 9 ± 2 days. The rate at which surgeons resorted to open surgery was 9%. All of the patients recovered well and were favourably discharged from the hospital. In the laparoscopic groups, the average duration of surgery was 142 ± 34 min, the average intraoperative blood loss was 251 ± 92 ml, the average post-operative hospital stay lasted 9 ± 3 days and the rate at which surgeons resorted to open surgery was 23%, because serious adhesions in the abdomen made the tissue structure difficult to distinguish. These findings are shown in Table 3.

Figure 7

Scar in the first open surgery vs in the repeat surgery of da Vinci robot of hepatocellular carcinoma

Table 3

Comparison of patient with robot-assisted and laparoscopic system on recurrent hepatocellular carcinoma (X̄±S)

Group	The operative time (min)	The blood loss (ml)	Hospital time (days)	Turned to open surgery rate (%)	Serious complication
A	152±25	284±89	9±2	9	0
B	142±34	251±92	9±3	23	0
T	0.45	0.39	0.92
χ 2				8.19
P	>0.05	>0.05	>0.05	<0.05

A: Robot-assisted groups, B: Laparoscopic groups

DISCUSSION

HCC is a common disease and a leading cause of disease-related deaths worldwide.[131415] These diseases can be treated with such curative therapies as surgery. However, the overall recurrence rate is about 70% of HCC cases recur within a 5-year period.[45616] Many of these patients may be treated with surgery again. However, we found that patients who were typically treated through the traditional open repeat LR had severe incisional scars, which could induce high post-operative infection rates and poor healing [Figure 7]. Some patients had severe intraoperative abdominal adhesions [Figures 3-6], adhesions that were difficult to separate, large amounts of bleeding and the inability to undergo repeat surgery. Larger studies have shown that repeat laparoscopic hepatic resections can be performed safely, especially in patients who have undergone previous laparoscopic resections.[7171819] However, the abnormal anatomical structure, narrow space available for operation in the abdominal adhesions and abundant hepatobiliary vessels make the treatment of rHCC extremely challenging in laparoscopic views.

In our centre, we no longer avoid the use of laparoscopy in patients who have undergone previous open LR.[7] Due to difficulties encountered in laparoscopic surgery, we decided to use the da Vinci robot. First, adhesions of the abdominal wall were separated under direct lens vision. Then, the da Vinci robot ports were set and docked. This is shown in Figures 3 and 4. In fact, the separation of the abdominal adhesion is easier and more accurate under the effect of 3D image and magnification of da Vinci robot after docking, which could reduce the risk of bowel injury and other complications.[2021] Next, the use of wristed instruments facilitates exposure of the surgical field of vision by pulling or pushing tissue, and it allows precise dissection and suturing whenever necessary in a limited workspace.[22] This is shown in Figure 3. Finally, complicated surgeries is performed safely for stable surgical manipulations with the anti-shake function of robotic systems, although these can cause some discomfort to the surgeon.

In our studies, ten patients successfully underwent surgery using a da Vinci robot. The incision scar was small and has healed well [Figure 7]. The average duration of surgery was 152 ± 25 min, which included the time consumption for such preparations as docking the da Vinci robot. There was less average intraoperative blood loss and the average post-operative hospital time was not long. There are no serious complications. However, these were not advantages. The rate at which surgeons switched to open surgery was lower than with laparoscopic systems (9% vs. 23%, P < 0.05). We believe the patient may benefit from the good surgical vision and flexible wrist handling of the da Vinci robot. For these reasons, we consider da Vinci robots to be safe, efficient and suitable for rHCC surgery. Several experts have also shown that robotic approaches involve shorter hospital stays, fewer post-operative complications and excellent perioperative outcomes.[2324] However, a greater proportion of rHCC surgery to be completed using a robotic approach was still observed.

CONCLUSION

Da Vinci robots can provide a precise dissection of the tissue under a perfect view. It is a technically feasible procedure for less rates at which surgeons switched to open surgery on repeat HCC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.