Robotic liver surgery

Robotic surgery is an evolving technology that has been successfully applied to a number of surgical specialties, but its use in liver surgery has so far been limited. In this review article we discuss the challenges of minimally invasive liver surgery, the pros and cons of robotics, the evolution of medical robots, and the potentials in applying this technology to liver surgery. The current data in the literature are also presented.     

Robotic renal surgery for renal cell carcinoma with inferior vena cava thrombus

Surgical management of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus is inherently complex, posing challenges for even the most experienced urologists. Until the mid-2000s, nephrectomy with IVC thrombectomy was exclusively performed using variations of the open technique initially described decades earlier, but since then several institutions have reported their robotic experiences. Robotic IVC thrombectomy was initially reported for level I and II thrombi, and more recently in higher-lever III thrombi. In general, the robotic approach is associated with less blood loss and shorter hospital stays compared to the open approach, low rates of open conversion in reported cases, relatively low rates of high-grade complications, and favorable overall survival on short-term follow-up in limited cohorts. Operative times are longer, costs are significantly higher, and left-sided tumors always require intraoperative repositioning and usually require preoperative embolization. To date, criteria for patient selection or open conversion have not been defined, and long-term oncologic outcomes are lacking. While the early published robotic experience demonstrates feasibility and safety in carefully selected patients, longer-term follow-up remains necessary. Patient selection, indications for open conversion, logistics of conversion particularly in emergent settings, necessity and safety of preoperative embolization, the value proposition, and long-term oncologic outcomes must all be clearly defined before this approach is widely adopted.     

Robotic colorectal surgery

Master–slave manipulators (otherwise known as telemanipulators) were introduced into minimally invasive surgery in the 1990s to overcome the limitations of laparoscopic surgery. This led to the development of the first robotic surgical systems which, over the last 10 years, have rapidly gained acceptance among colorectal surgeons. Advantages of robotic surgical systems such as superior instrumentation and field of vision enable precise dissection in confined spaces such as the pelvis which make it a particularly attractive tool for rectal surgery. The feasibility and safety of robotic rectal surgery is now well established and there is increasing evidence that it might offer superior peri- and postoperative outcomes when compared to laparoscopic rectal surgery. Robotic rectal surgery is easier to learn than laparoscopic surgery and the creation of a structured training programme for robotic rectal surgery in Europe has facilitated the learning of this technique in an environment that promotes patient safety and improved patient outcomes through equipment fidelity and operator skill. It is foreseeable that in the near future robotic systems will become part of routine surgical practice in colorectal surgery.     

Principles of laparoscopic surgery

Laparoscopic surgery is currently established as the primary modality for many procedures. It has been associated with a number of benefits over traditional open surgery, including reduced pain, shorter hospital stay and quicker return to work. Despite this, significant operative challenges and the potential for life-threatening complications exist. Surgeons must understand the specialist equipment that is required, along with how to troubleshoot common issues. Furthermore, an appreciation of the distinctive surgical techniques and technical challenges is critical in limiting the risk of significant complications. Through this article we discuss these topics in the context of the current literature, aiming to recognize common pitfalls that all surgeons should make a conscious effort to avoid. We will describe those patient groups, specifically obesity, pregnancy, elderly and bowel obstruction, in whom additional caution must be maintained. Finally, we will consider these principles in the context of the wider field of minimally invasive surgery, to include robotics, single incision, transanal microsurgery (TAMIS) and transanal total mesorectal excision (TaTME). Although the landscape of minimally invasive surgery is constantly evolving, a robust understanding of the underlying principles is essential for all surgeons.     

Principles of laparoscopic surgery

Laparoscopic surgery is currently established as the primary modality for many procedures. In has been associated with a number of benefits over traditional open surgery, including reduced pain, shorter hospital stay and quicker return to work. Despite this, significant operative challenges and the potential for life-threatening complications exist. Surgeons must understand the specialist equipment that is required, along with how to troubleshoot common issues. Furthermore, an appreciation of the distinctive surgical techniques and technical challenges is critical in limiting the risk of significant complications. Through this article we discuss these topics in the context of the current literature, aiming to recognize common pitfalls that all surgeons should make a conscious effort to avoid. We will describe those patient groups, specifically obesity, pregnancy, elderly and bowel obstruction, in whom additional caution must be maintained. Finally, we will consider these principles in the context of the wider field of minimally invasive surgery, to include robotics, single incision, transanal microsurgery (TAMIS) and transanal total mesorectal excision (TaTME). Although the landscape of minimally invasive surgery is constantly evolving, a robust understanding of the underlying principles is essential for all surgeons.