Robotic Liver Surgery

Robotic surgery is currently hailed as a major technological advance in surgery. A surgeon performs minimally invasive abdominal surgery not at the patients bedside but some distance away with the aid of a robot. This simple statement contains three major paradigm shifts in traditional surgery. Firstly, major abdominal surgery that were thought impossible to be performed in a minimally invasive way are now being “rediscovered” with the laparoscope manipulated by the robot. Secondly, the surgeon operating at the patient’s bedside is soon to be a relic of the past. Thirdly, surgery will now be a team effort with a second surgeon at the patient’s bedside.

Surgeon At the Console

Second Surgeon at the Bedside

The liver, more than any other abdominal organs, has always inspired respect. The vascularity and the anatomy of the liver are complex and demanding. Blood loss and the necessity to perform large operations i.e., right or left hepatectomy have always been an impediment to performing it in a minimally invasive way. Even with open techniques, surgery on this organ is best performed by surgeons specialized in this area of surgery

Advances in the techniques in surgery as well a better understanding of the anatomy in tandem with technological advances in equipment have now placed liver surgery within the realm of minimally invasive surgery.

The more traditional surgeon would operate on the liver in an “open” manner requiring a scalpel for the skin incision, retractors for the abdomen. Scissors and forceps and sutures and perhaps an ultrasonic dissector for liver transection. The robotic surgeon can trade the scalpel for the laparoscopic ports, fine robotic handling tissue forceps and the harmonic scalpel for the liver trancestion.

The main difference between open and robotic liver surgery is mainly the time. A robotic segmental resection can take up to 4 hours while an open one would take 2 to 3 hours.

At Mount Elizabeth we have embarked on a program to incorporate the Da Vinci root into our surgical armamentarium. We have performed 5 liver operations using the Da Vinci robot. One of which is a resection of a tumour in a young girl. This is the first Robotic Liver resection in Asia.

This 25 year old girl had a pedunculated tumour measuring 6 cm in diameter in the right side of the liver. A “open” approach would have left her with a large scar. Traditional Laparoscopy was more difficult and risky for this right sided liver tumour. In general most traditional Laparoscopic surgical operations are performed on the left side which is easier and safer to perform.

CT SCAN SAGITTAL VIEW OF TUMOR

CT SCAN CORONAL VIEW OF TUMOUR

Thus we felt that she would be an ideal case for the robot. On a background of 5 previous operations on the liver for the removal of giant cysts and 6 operations on the left side of the liver using standard Laparoscopic methods, we performed a resection of Segment 5 and Segment 6 of the liver. The operation was uneventful and took 4 hours. However she was discharged on the 3rd post-operative day. This is probably the most remarkable benefit of using a minimal access method. She was able to return to Indonesia two days later. In conventional approaches she would have to stay in Singapore for at least a week following surgery for wound management.

Robotic Liver Surgery is a giant Leap forward in Liver surgery as it allows complex tumors to be removed in a minimal access method. Keyhole Surgery allows speedier recovery and can be performed safely. However patient selection is important as not all cases can be performed with the robot.