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  Table of Contents  
Year : 2017  |  Volume : 54  |  Issue : 1  |  Page : 52-55

Robotic resections in hepatobiliary oncology – initial experience with Xi da Vinci system in India

Department of Gastrointestinal and Hepato-pancreato-biliary Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India

Date of Web Publication1-Dec-2017

Correspondence Address:
Dr. M Goel
Department of Gastrointestinal and Hepato-pancreato-biliary Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_132_17

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 » Abstract 

INTRODUCTION: Minimal invasive surgery has proven its advantages over open surgeries in the perioperative period. Food and Drug Administration approved da Vinci robot in 2000. The latest version, da Vinci Xi system has a mobile tower-based robot with several modifications to improve the functionality, versatility, and operative ease. None of the centers have reported exclusively on hepatobiliary oncology using the da Vinci Xi system. We report our initial experience. AIMS AND OBJECTIVES: To study the feasibility, advantages, and discuss the operative technique of da Vinci Xi system in hepatobiliary oncology. MATERIALS AND METHODS: Data were analyzed retrospectively from a prospectively maintained database from June 2015 to October 2016. Twenty-five patients with suspected or proven hepatobiliary malignancies were operated. Total robotic technique using da Vinci Xi system was used. Demographic details and perioperative outcomes were noted. RESULTS: Of the 25 surgeries, 14 patients had a suspected gallbladder malignancy, 11 patients had primary or metastatic liver tumor. Median age was 53 years. The average duration of surgery was 225 min with a median blood loss 150 ml. The median postoperative stay was 4 days. The median nodal yield for radical cholecystectomy was seven. Five patients required conversion. Two of these developed postoperative morbidity. CONCLUSION: Robotic surgery for hepatobiliary oncology is feasible and can be performed safely in experienced hands. Increasing experience in this field may equal or even prove advantageous over conventional or laparoscopic approach in future. A cautious approach with judicious patient selection is the key to establishing robotic surgery as a standard surgical approach.

Keywords: Hepatobiliary oncology, mimimally invasive surgery, robotic surgery

How to cite this article:
Chandarana M, Patkar S, Tamhankar A, Garg S, Bhandare M, Goel M. Robotic resections in hepatobiliary oncology – initial experience with Xi da Vinci system in India. Indian J Cancer 2017;54:52-5

How to cite this URL:
Chandarana M, Patkar S, Tamhankar A, Garg S, Bhandare M, Goel M. Robotic resections in hepatobiliary oncology – initial experience with Xi da Vinci system in India. Indian J Cancer [serial online] 2017 [cited 2021 Aug 1];54:52-5. Available from: https://www.indianjcancer.com/text.asp?2017/54/1/52/219536

 » Introduction Top

Robotic surgery has been evolving over the past two decades. After Food and Drug Administration approval of the da Vinci robot (Intuitive Surgical, Sunnyvale, CA, USA), the indications of robotic surgery have expanded. The da Vinci Xi system introduced in 2014 has many technical modifications to benefit the operating surgeon and eventually improve patient outcomes. Xi system has a mobile tower-based robot thus facilitating surgeries to be performed with a single docking single-phase technique. This has greater scope in surgeries to be performed in multiple quadrants of the abdomen or on different parts of the body without the need to re-dock the robot. Our hospital, a tertiary care cancer center has installed the Xi system, thus opening the gateway of robotic surgery for cancer patients to be performed at reasonable costs.

The Xi robotic experience in hepatobiliary cancers is limited. None of the centers have reported exclusively on hepatobiliary oncology procedures with the Xi system. We report our initial experience with hepatobiliary cancers using the Xi da Vinci robot at a tertiary referral center.

 » Materials and Methods Top

Twenty-five patients of proven or radiologically suspected hepatobiliary malignancy from June 2015 to October 2016 were operated using the Xi da Vinci robotic system by a single, trained robotic surgeon. The surgeon performing robotic surgeries underwent a certified training program in the USA before starting robotic surgery. Since robotic hepatobiliary surgery is a new field in India and the surgeon being a well-established hepatobiliary surgeon, no mentor was involved in any of the surgeries performed. Total robotic technique was used in all patients. The perioperative outcomes were analyzed retrospectively from a prospectively maintained database. Procedures started on the Xi system and changed to either laparoscopic or open approach were considered as conversions. The complications were accounted for 30 days after surgery and were reported using the Dindo et al. classification.[1] Complications with Grade II or higher grade were recorded, with Grade III or more regarded as major complications.

Surgical technique

The surgery was performed with a total robotic technique. Four (8 mm) robotic ports and one (12 mm) assistant port (AirSeal Cannula, SurgiQuest, Intuitive Surgical, Sunnyvale, CA, USA) were used for the procedures. The camera port was placed 1 cm infraumbilical in the midline. The other ports were placed using a 30° camera after creating pneumoperitoneum. Three ports were placed along a straight line from the right anterior superior iliac spine to below the umbilicus [Figure 1], R1–R3]. The fourth port (R4) was placed between the R3 port and the left costal margin above the straight line joining the first three ports. An assistant port was used for suction and traction. Camera was inserted through the second or third robotic arm [Figure 1], R2 or R3]. Arms on either side of the camera port were working arms [Figure 1]. Patients were operated with a 45° reverse Trendelenburg position and a lateral tilt depending on the side of liver to be operated. The same position was maintained throughout the procedure.
Figure 1: Robotic port placement (R1–R4) with the assistant port (A)

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Before docking, the patient anatomy was selected on the patient cart as upper abdomen, left side – which is defined as per the position of robot relative to the patient. Robotic arms were then deployed. Laser pointer in the overhead boom was used to center the boom over the camera port [Figure 2]. Camera was inserted through arm R2 or R3. “Targeting” was performed which helps in automatic alignment of the other arms and the overhead boom as per the preset configuration [Figure 3]. Other instruments were inserted through the respective arms. Placements for instruments depend on the side of the liver to be operated. Instruments can be changed or interchanged as needed.
Figure 2: Laser pointer in the overhead boom centered at the camera port

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Figure 3: Targeting of operative anatomy at the liver

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For a radical cholecystectomy, the falciform ligament was hitched to the anterior abdominal wall with a suture and simultaneously duodenum is then retracted down using rolled up gauze with a ProGrasp forceps to open up the porta for portal dissection. Dissection then commenced at the porta. Starting with the identification of hepatic artery, all nodal tissue around the hepatic artery, bile duct and portal vein was excised. Cut margin of cystic duct was sent separately for frozen section. Gall bladder was then excised with a 2.5–3 cm wedge of liver in the gallbladder fossa. A similar procedure was done for a simple cholecystectomy, except that the liver wedge and portal lymphadenectomy are performed after confirmation of diagnosis on frozen section. For hepatic resections, portal dissection was the first step, to identify and delineate branches of the hepatic artery and portal vein. Lobar vessels were then looped. For a left sectionectomy, all pedicles to left of falciform ligament or ligamentum teres were carefully delineated and transected with clips or vascular stapler. This guides the plane of transection, which was performed with a bipolar cautery. A nonanatomical transection proceeded directly with hepatic resection with an adequate margin around the tumor without any portal isolation or clamping as for anatomical resections.

 » Results Top

Demographic profile of patients is shown in [Table 1]. Of the 25 surgeries, 14 patients had a proven or suspected malignancy of the gallbladder and 11 patients had a primary liver tumor or metastasis to the liver. The distribution of surgeries in elaborated in the table.
Table 1: Demographic and clinicopathologic parameters

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The average time required for all surgeries was 225 min (range 60–285 min), and the median blood loss was 150 ml (range 50–3500 ml). Median postoperative hospital stay was 4 days (range 2–21 days).

Two patients had intraoperative complications; one patient had an iatrogenic duodenal perforation while retracting the duodenum with a ProGrasp forceps and other developed hypotension secondary to underestimated blood loss and steep reverse Trendelenburg position. Both these patients required conversion to open surgery. The patient with intraoperative hypotension had a prolonged Intensive Care Unit stay and developed pneumonia and septicemia. He had an iatrogenic sigmoid perforation after a colonoscopy performed for per-rectal bleeding requiring reexploration but succumbed to multiorgan failure on postoperative day 22. Three other patients needed conversion to open surgery. In one patient of liver metastatectomy, lesion was not visualized during surgery as well as on specimen ultrasound after resection of the suspected region, underscoring the need for robotic intraoperative ultrasonography. In another patient, there was an instrument failure, and thus conversion was purely due to a technical failure. The last patient was an 84-year-old man being operated for a hepatocellular carcinoma. Robotic approach was evaluated due to an exophytic mass on imaging studies. The mass was very friable and highly vascular and in view of the old age of the patient, a timely decision to convert to open surgery was taken.

 » Discussion Top

Over the years, there has been a shift from open to minimal access approach for many surgeries. Minimal invasive surgery has proven its advantages over open surgery with comparable or even superior perioperative outcomes. Hepatobiliary surgeries, especially liver surgeries pose a unique challenge in minimal access. Its deep anatomical location, vascularity, and volume make basic maneuvers of open liver surgery technically difficult during minimal invasive approach.[2] Robotic surgery has advantages over laparoscopic surgery in terms of superior dexterity, stable operating platform, surgeon-controlled camera, and three-dimensional vision. Evidence from a single meta-analysis [3] has shown superior perioperative outcomes with robotic surgery as compared to laparoscopy, for gastrectomy and cholecystectomy.

Robotic surgery has had improvements in visualization, functionality, and operational ease of use with each successive generation, contrasting with laparoscopy. The recently introduced da Vinci Xi system (Intuitive Surgical) provides a scalable platform that allows movement of arms relative to its base and aids multi-quadrant or multi-cavity surgery without re-docking of robotic arms.[4] Earliest reports of a hepatectomy using da Vinci system were reported from Japan by Wakabayashi et al. They later reported their experience of 52 robotic surgeries, which included 28 hepatobiliary-pancreatic surgeries, both benign and malignant.[5] Data on robotic hepatobiliary resections are limited, largest of which comes from Giulianotti et al., Italy, a series of seventy robotic liver resections.[6] Our hospital is the first hospital in India to use da Vinci robotic Xi system for surgeries. Data in the field of robotic surgical oncology are still emerging. Yuh et al. from City of Hope Hospital, California recently reported on 112 surgical oncology cases using the Xi system. It included 8 hepatobiliary malignancies and conversion in 3 of 112 patients operated with the Xi system.[4] Robotic surgery has a definite learning curve, and we believe our conversion rate will gradually reduce with experience of operating surgeons. Furthermore, a laparoscopic or robotic intraoperative ultrasound is mandatory for performing advanced liver surgeries. Postoperative complications occurred in only those two patients who had intraoperative complications requiring conversion to open surgery and reflect the importance of judicious patient selection. Average postoperative stay in the hospital was 4 days, which is lesser than that for open hepatobiliary surgeries at our institute.

Stringent selection criteria should be applied for selecting patients for robotic surgery, especially hepatobiliary surgeries. From our limited experience of just over a year, we have not yet expanded our indications for robotic hepatobiliary surgeries. We choose patients wisely – early stage gall bladder cancer patients with limited lymph nodal involvement if any and surface liver metastases from our majority of the cases. Patients should preferably have a lower body mass index, a good performance status, and no or limited comorbidities. The first major robotic hepatectomy was performed after twenty robotic hepatobiliary surgeries. It was multi-quadrant surgery, as the patient needed a bilateral oophorectomy as well. Our first attempt for a pancreatic resection was 23rd on the list – a distal pancreatectomy with simple cholecystectomy. Thus, major surgeries can be safely attempted with gain in experience.

Main drawback of the study is a relatively small number of patients. However, more experience and evidence will generate with time. Our experience also shows that robotic surgery is definitely a feasible approach in judiciously selected patients. It is necessary to set up a team experienced in robotic surgery, including a surgeon, assistants, and theater personnel for smooth functioning and improved results.

 » Conclusion Top

Robotic surgery even for hepatobiliary oncology is feasible and can be performed safely in experienced hands. Increasing experience in this field may equal or even prove advantageous over conventional or laparoscopic approach in future. A cautious approach with judicious patient selection is the key to establishing robotic surgery as a standard surgical approach.


We would like to thank Department of HPB and Gastrointestinal Surgery and Surgical Oncology, Tata Memorial Centre, Mumbai, India.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13.  Back to cited text no. 1
Cherqui D. Laparoscopic liver resection. Br J Surg 2003;90:644-6.  Back to cited text no. 2
Maeso S, Reza M, Mayol JA, Blasco JA, Guerra M, Andradas E, et al. Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: A systematic review and meta-analysis. Ann Surg 2010;252:254-62.  Back to cited text no. 3
Yuh B, Yu X, Raytis J, Lew M, Fong Y, Lau C. Use of a mobile tower-based robot – The initial Xi robot experience in surgical oncology. J Surg Oncol 2016;113:5-7.  Back to cited text no. 4
Wakabayashi G, Sasaki A, Nishizuka S, Furukawa T, Kitajima M. Our initial experience with robotic hepato-biliary-pancreatic surgery. J Hepatobiliary Pancreat Sci 2011;18:481-7.  Back to cited text no. 5
Giulianotti PC, Coratti A, Sbrana F, Addeo P, Bianco FM, Buchs NC, et al. Robotic liver surgery: Results for 70 resections. Surgery 2011;149:29-39.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]

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