Setting up a robotic hepatectomy program: a Western-European experience and perspective.

Currently the majority of liver resections are performed via open resection. Nevertheless, minimally invasive liver surgery is gaining ground and conventional laparoscopy has proven to be beneficial in different fields of liver surgery compared to open resections. Still, conventional laparoscopy has a few downsides, from which straight instruments, 2-dimensional view and awkward ergonomics are the most obvious. The robotic surgical system is developed to overcome these limitations. It offers several advantages over conventional laparoscopy to optimize conditions in minimally invasive surgery: instruments are wristed with a wide range of motion and the view is 3-dimensional and magnified. With instruments with a greater range of motion than in laparoscopic surgery, the use of a robotic system potentially broadens indications for minimally invasive liver resection. Here, we discuss the steps of setting up a robotic hepatectomy program against the background of the initial experience at our institution.

Robot-assisted laparoscopic liver resection: a systematic review and pooled analysis of minor and major hepatectomies.

BACKGROUND: Robotic surgery has been introduced to overcome the limitations of conventional laparoscopy. A systematic review and meta-analysis were performed to assess the safety and feasibility for three subgroups of robot-assisted laparoscopic liver resection: (i) minor resections of easily accessible segments: 2/3, 4B, 5, 6, (ii) minor resections of difficult located segments: 1, 4A, 7, 8 and (iii) major resections: ≥ 4 segments. METHODS: A systematic search was performed in PubMed, EMBASE and Cochrane Library. RESULTS: Twelve observational, mostly retrospective studies reporting on 363 patients were included. Data were pooled and analyzed. For subgroup (i) (n = 81) the weighted mean operative time was 215 ± 65 min. One conversion (1%) to laparotomy was needed. Weighted mean operative time for subgroup (ii) (n = 17) was 220 ± 60 min. No conversions were needed. For subgroup (iii) (n = 99) the weighted mean operative time was 405 ± 100 min. In this subgroup 8 robotic procedures (8%) were converted to open surgery. CONCLUSION: Data show that robot-assisted laparoscopic liver resection is feasible in minor resections of all segments and major resections. Larger, prospective studies are warranted to compare the possible advantages of robot-assisted surgery with conventional laparoscopy and open surgery.

Intravital microscopy through an abdominal imaging window reveals a pre-micrometastasis stage during liver metastasis.

Cell dynamics in subcutaneous and breast tumors can be studied through conventional imaging windows with intravital microscopy. By contrast, visualization of the formation of metastasis has been hampered by the lack of long-term imaging windows for metastasis-prone organs, such as the liver. We developed an abdominal imaging window (AIW) to visualize distinct biological processes in the spleen, kidney, small intestine, pancreas, and liver. The AIW can be used to visualize processes for up to 1 month, as we demonstrate with islet cell transplantation. Furthermore, we have used the AIW to image the single steps of metastasis formation in the liver over the course of 14 days. We observed that single extravasated tumor cells proliferated to form "pre-micrometastases," in which cells lacked contact with neighboring tumor cells and were active and motile within the confined region of the growing clone. The clones then condensed into micrometastases where cell migration was strongly diminished but proliferation continued. Moreover, the metastatic load was reduced by suppressing tumor cell migration in the pre-micrometastases. We suggest that tumor cell migration within pre-micrometastases is a contributing step that can be targeted therapeutically during liver metastasis formation.

I-131 accumulation in a benign cystic mesothelioma in a patient with follicular thyroid cancer.

Focal I-131 accumulation is generally a reliable indicator of functioning normal thyroid tissue or a differentiated thyroid cancer metastasis. However, physiologic accumulation of activity may also be observed in organs such as the intestinal tract, liver, and salivary glands. Extrathyroidal I-131 accumulation has been reported in various sites, such as ectopic gastric mucosa, gastrointestinal and urinary tract abnormalities, cysts (mammary, liver, kidney, and ovaries), and inflammation and infection foci. We report a case of focal I-131 accumulation in a benign cystic mesothelioma in a patient with follicular thyroid cancer.

Adequate symptom relief justifies hepatic resection for benign disease.

BACKGROUND: The purpose of this study was to evaluate the long-term results of partial liver resection for benign liver lesions. METHODS: All patients operated on for benign liver lesions from 1991 to 2002 were included. Information was retrieved from medical records, the hospital registration system and by a telephonic questionnaire. RESULTS: Twenty-eight patients with a median age of 41 years (17-71) were operated on (M/F ratio 5/23). The diagnosis was haemangioma in 8 patients, FNH in 6, HCA in 13 and angiomyolipoma in 1. Eight patients were known to have relevant co-morbidity. Median operating time was 207 minutes (45-360). The morbidity rate was 25% and no postoperative mortality was observed. Twenty-two patients (79%) had symptoms (mainly abdominal pain) prior to surgery. Twenty-five patients were reached for a questionnaire. The median follow up was 55 months (4-150). In 89% of patients preoperative symptoms had decreased or disappeared after surgery. Four patients developed late complications. CONCLUSION: Long-term follow up after liver surgery for benign liver lesions shows considerable symptom relief and patient satisfaction. In addition to a correct indication these results justify major surgery with associated morbidity and mortality.