Background: Robotic liver surgery (RLS) has become the preferred minimally invasive approach for liver surgery. However, especially for complex RLS (C-RLS), key surgical steps such as preoperative preparation, intraoperative techniques, and training are often center-dependent and not standardized. The aim of this survey was to assess the international practice of key surgical steps during C-RLS among expert centers. Methods: A cross-sectional survey was conducted among robotic liver surgeons with a minimum individual experience of 50 RLS to assess their practice during C-RLS. The survey consisted of 50 questions, distributed across three sections: training, preoperative planning, and intraoperative practice for C-RLS. Results: 60 out of 71 experts completed the survey, corresponding to an 85% response rate. 73% of the experts agreed that the IWATE difficulty score represents an adequate classification system to define C-RLS. A prerequisite before performing C-RLS was experience in complex open liver surgery (71%) and expertise in low and intermediate RLS (75%). Mentoring by a more experienced surgeon was deemed necessary by most experts (90%) when performing C-RLS. Vascular inflow control was mentioned to often be performed during parenchyma transection either selectively (38%) or routinely (52%). Most experts considered pre- or intraoperative positive staining helpful (57%), while negative staining (85%) was reported as even more important in C-RLS. For vasculo-biliary transection, experts preferred an intrafascial (45%), glissonian pedicle approach (33%) or a case-dependent transection (12%). For parenchymal transection, the preferred instruments were laparoscopic CUSA (92%), harmonic ACE (78%), and SynchroSeal (77%). Conclusion: This expert survey reveals current international practices for preoperative preparation, training, and intraoperative key steps of C-RLS. Prospective validation of the key steps would be useful for correlating clinical outcomes with current practice.
Key steps of complex robotic liver surgery: an international expert survey / Aegerter, N. L. E.; Kuemmerli, C.; Nickel, F.; Guidetti, C.; Tschuor, C.; Lopez-Lopez, V.; Wakabayashi, T.; Dutkowski, P.; Billeter, A. T.; Muller, B. P.; Muller, P. C.; De Wilde, R.; Wakabayashi, G.; Troisi, R. I.; Toso, C.; Swijnenburg, R. -J.; Sutcliffe, R. I.; Sucandy, I.; Strucker, B.; Stattner, S.; Starlinger, P.; Soubrane, O.; Seehofer, D.; Schmelzle, M.; Scatton, O.; Saint-Marc, O.; Robles-Campos, R.; Reissfelder, C.; Ratti, F.; Rahbari, N.; Primavesi, F.; Pratschke, J.; Marques, H. P.; Park, J.; Panaro, F.; Oberkofler, C. E.; Nakano, Y.; Memeo, R.; Martinie, J. B.; Machado, M.; Lurje, G.; Lin, C. C. -W.; Lim, C.; Lesurtel, M.; Lee, J. H.; Kron, P.; Kawaguchi, Y.; Jonas, J. P.; D'Hondt, M.; Heumann, A.; He, J.; Hawksworth, J.; Hagendoorn, J.; Goh, B. K. P.; Gilg, S.; Geller, D.; Ferrero, A.; Di Benedetto, F.; Croner, R.; Cheah, Y. L.; Cao, H. T.; Broring, D. C.; Boggi, U.; Alseidi, A.; Aldrighetti, L.; Ahmad, J.; Hilal, M. A.; Abe, Y.. - In: SURGICAL ENDOSCOPY. - ISSN 0930-2794. - 39:10(2025), pp. 6692-6701. [Epub ahead of print] [10.1007/s00464-025-12020-9]
Key steps of complex robotic liver surgery: an international expert survey
Ratti F.;Aldrighetti L.;
2025-01-01
Abstract
Background: Robotic liver surgery (RLS) has become the preferred minimally invasive approach for liver surgery. However, especially for complex RLS (C-RLS), key surgical steps such as preoperative preparation, intraoperative techniques, and training are often center-dependent and not standardized. The aim of this survey was to assess the international practice of key surgical steps during C-RLS among expert centers. Methods: A cross-sectional survey was conducted among robotic liver surgeons with a minimum individual experience of 50 RLS to assess their practice during C-RLS. The survey consisted of 50 questions, distributed across three sections: training, preoperative planning, and intraoperative practice for C-RLS. Results: 60 out of 71 experts completed the survey, corresponding to an 85% response rate. 73% of the experts agreed that the IWATE difficulty score represents an adequate classification system to define C-RLS. A prerequisite before performing C-RLS was experience in complex open liver surgery (71%) and expertise in low and intermediate RLS (75%). Mentoring by a more experienced surgeon was deemed necessary by most experts (90%) when performing C-RLS. Vascular inflow control was mentioned to often be performed during parenchyma transection either selectively (38%) or routinely (52%). Most experts considered pre- or intraoperative positive staining helpful (57%), while negative staining (85%) was reported as even more important in C-RLS. For vasculo-biliary transection, experts preferred an intrafascial (45%), glissonian pedicle approach (33%) or a case-dependent transection (12%). For parenchymal transection, the preferred instruments were laparoscopic CUSA (92%), harmonic ACE (78%), and SynchroSeal (77%). Conclusion: This expert survey reveals current international practices for preoperative preparation, training, and intraoperative key steps of C-RLS. Prospective validation of the key steps would be useful for correlating clinical outcomes with current practice.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
