Introduction We undertook this study to describe the number and variety of robotic operations undertaken for hepatopancreatic and esophageal disorders. Methods Data from 2015 through March of 2018 were analyzed for da Vinci™ robot application for hepatopancreatic disorders, gastroesophageal reflux disease (GERD), and achalasia. Results From 2015 through 2017, robotic hepatopancreatic operations increased 49%, robotic hepatic operations increased 107%, and robotic pancreatic operations increased 26%. Quarter after quarter, robotic application increased for hepatopancreatic operations, hepatic operations, and pancreatic operations ( P < .001 for each) with acceleration over the most recent months. The application of the Xi robot platform increased from 12% of robotic hepatopancreatic operations in 2015-71% in 2018 (1075% increase in numbers). From 2015 through 2017, robotic fundoplications and myotomies increased by 55%, robotic fundoplications increased by 59%, and robotic Heller myotomies increased by 211%. Quarter after quarter, robotic application increased for fundoplications and Heller myotomies ( P < .001 for each) with acceleration over the most recent months. The application of the Xi robot platform increased from 13% of these robotic operations in 2015-64% in 2018 (935% increase in numbers). Less than 10% of hepatopancreatic operations, fundoplications, and myotomies are undertaken robotically. Conclusions There has been an accelerating increase in the number of robotic operations for hepatopancreatic disorders, GERD, and achalasia over the past 3 ¼ years. Application of the Xi robot has dramatically increased, both absolutely and relatively. Still only a small proportion of operations for hepatopancreatic disorders, GERD, and achalasia use the robotic platform; this is changing fast.

BACKGROUND:This study was undertaken to determine if age influences postoperative outcomes for patients undergoing robotic major hepatectomy.METHODS:Ninety-four patients undergoing robotic major hepatectomy were prospectively followed. With regression analysis, demographic data and postoperative outcomes were compared to age. Data are presented as median (mean ± SD).RESULTS:Overall, the patients were of age 62 (61 ± 13) years, body mass index (BMI) of 29 (29 ± 5.9) kg/m2, and American Society of Anesthesiologists (ASA) class of 3 (3 ± 0.5). The mass size was 5 (5 ± 3.0) cm. The operative duration was 252 (276 ± 106) minutes with an estimated blood loss (EBL) of 175 (249 ± 275.9) mL. One operation was converted to "open" due to bleeding, accounting for the only intraoperative complication. Nine patients required intensive care unit (ICU) admission. Postoperatively, 7 patients had complications with no in-hospital mortalities, and a length of stay (LOS) of 4 (5 ± 2.6) days. Thirteen patients were readmitted within 30 days with 0 deaths within 30 days.A significant relationship was found between age and ASA class (P = .001) and LOS (P = .03). No correlation was found when comparing age to operative duration, EBL, ICU admission, ICU duration, complications, and readmission within 30 days.CONCLUSION:For patients undergoing robotic major hepatectomy, there was no significant correlation between age and perioperative outcomes, with the exception of LOS. Increasing age is not associated with increased morbidity or perioperative mortality. With the application of innovative technology, that is, the robotic approach, surgeons should be encouraged to undertake major hepatectomy in elderly patients deemed candidates for surgery.

Introduction: This study was undertaken to examine our institutional experience with major robotic liver resections for malignant lesions and to identify factors affecting patient outcomes. Methods: Patients undergoing robotic major hepatectomy from 2013 to 2019 were prospectively followed. Patients were stratified by pathology and analyzed utilizing Cox Proportional-Hazards analysis and multivariate linear regression to evaluate associations between patient survival and predictor variables. Results: 80 patients underwent robotic major hepatectomy, of which, 34% were for colorectal liver metastasis, 33% for hepatocellular carcinoma, 16% for intrahepatic cholangiocarcinoma, 5% for gallbladder cancer, and 12% for 'other' malignant lesions. Median age was 65 years (63±12.5), 46% were women, BMI was 28 (28±6.0) kg/m2 and ASA Class was 3 (3± 0.6). Five patients experienced postoperative complications. 11 patients were readmitted within 30 days.Disease free survival, overall survival, operative duration, estimated blood loss (EBL), conversions to open, perioperative complications, tumor size, length of stay, in-hospital mortality, readmission within 30days are stratified by pathology and depicted in Table1 and Figure1. Patients with intrahepatic cholangiocarcinoma had a significantly larger tumor size and consequently longer operative time (p=0.001, p=0.01, respectively). Patients undergoing resection for hepatocellular carcinoma had the longest disease-free survival, with a median disease-free survival of 55 months (b=-2.095, s.e.=0.946, p=0.027). Conclusion: Our experience supports that robotic major hepatectomy is safe and feasible for patients with malignant liver disease. Our complications were limited. A reduction in disease recurrence was noted in patients undergoing robotic major hepatectomy for hepatocellular carcinoma.

Introduction:The majority of published literature has only reported outcomes of robotic minor non-anatomical hepatectomy.We aim to examine our clinical outcomes, safety, and feasibly with robotic major hepatectomy.Methods: We prospectively followed 235 patients who underwent robotic hepatectomy since 2016.Major hepatectomy is defined as a resection of ≥ 3 segments.Data are presented as median (mean ± SD).Results: Of the 235 patients, 142 of the patients underwent a major hepatectomy.Median age was 63 (61 ± 14.0) years, 51% were women, BMI was 28 (29 ± 6.1) kg/m² and ASA Class was 3 (3 ± 0.5).25% of operations were for metastatic colorectal cancer, 23% for hepatocellular carcinoma, 11% cholangiocarcinoma, and 6% for gallbladder adenocarcinoma.Regarding the type of resection, 15 patients (11%) had central hepatectomy, 30 (21%) had formal right, 41 (29%) had formal left, 31 (22%) had non-anatomical right, 11 (8%) had non-anatomical left, 7 (5%) had extended right, and 7 (5%) had extended left.Prep time (in the room until incision) 64 (74 ± 67.3) minutes, Extraction time (incision until specimen extraction) 138 (159 ± 99.3) minutes, Console time 198 (213 ± 119.8) minutes, Closure time (extraction until dressing placement) 106 (214 ± 271.3) minutes, Operative duration was 288 (305 ± 119.0) minutes and time under anesthesia 359 (369 ± 115.6) minutes.Estimated blood loss was 200 (258 ± 252.1) mL and length of stay was 4 (5 ± 2.7) days.9 patients experienced postoperative complications (4 ileus, 1 pneumonia, 1 bile leak, 1 gram-negative bacteremia, 1 jaundice, 1 pneumothorax).22 patients were readmitted within 30 days with one death after readmission, due to aspiration.Conclusions: Application of the robotic platform to major hepatectomy is safe and feasible with excellent perioperative outcomes.

Ross, Sharona B. MD, FACS; Sucandy, Iswanto MD, FACS; Przetocki, Valerie BS; Luberice, Kenneth MD; Bourdeau, Timothy J. BS; Rivera-Espineira, Gabriel MD; Rosemurgy, Alexander S. MD, FACS Author Information

Ross, Sharona B. MD, FACS; Sucandy, Iswanto MD, FACS; Lippert, Trenton BS; Przetocki, Valerie BS; Crespo, Kaitlyn BS; Bourdeau, Timothy J. BS; Rosemurgy, Alexander S. MD, FACS Author Information

Introduction: Hepatectomy is the gold standard curative treatment for hepatic neoplasms in patients with preserved liver function. Many large tumors require extended hepatectomy (EH). Possibility of developing major postoperative complications including liver failure is feared by many surgeons. We aim to describe our outcomes of EH for large hepatobiliary tumors. Material and methods: All patients undergoing hepatectomy between 2012 and 2017 were prospectively followed. Results: 91 patients underwent hepatectomy with ten patients underwent EH. The majority of patients were women, age of 63, BMI of 24, and MELD score of 11. Six patients underwent an extended right hepatectomy, while four patients underwent extended left hepatectomy. Operative time was 224 min with estimated blood loss of 500 ml. No intraoperative complications were seen. Two patients experienced postoperative complications (pleural effusion in one patient and respiratory failure in another). Length of ICU stay was 2 days, and hospital stay was 5 days. 80% of the patients are currently alive with median follow-up of 41.2 months. Conclusion: EH can be undertaken safely with acceptable morbidity and mortality in our center. (C) 2019 Elsevier Inc. All rights reserved.

Objective: No data has yet been published correlating preoperative MRI staging and final TAMIS specimen pathology.The objective of this study is to report on such correlation.Methods and Procedures: All cases which were subjected to both MRI staging as well as TAMIS excision were identified.All 187 identified cases were retrospectively analyzed.The cases were performed between 2012-2019.Results: Only 39% (72/186) of cases resulted in MRI and pathological correlation.44% (83/186) of cases resulted in MRI over-staging.16% (29/186) of cases resulted in MRI under-staging.1% (2/186) of cases resulted in alternate non-suspected pathology (prostate cancer, inflammatory tissue containing staples).Conclusion: Only 39% of cases resulted in perfect correlation.44% of cases were over-staged by MRI, which could inadvertently result in eventual over-treatment.Judicious use of TAMIS excision for staging could help in reducing over-treatment.

BACKGROUND:Relative to conventional laparoscopy, Laparo-Endoscopic Single Site (LESS) surgery has been associated with improved cosmesis. This study investigated preoperative and postoperative patient perceptions of LESS surgery and what factors may affect those perceptions. METHODS:Patients undergoing LESS Surgery were queried before and after their operations. Body image and other factors were assessed preoperatively and postoperatively in 881unselected patients undergoing LESS surgery utilizing Likert scale questionnaires. Responses were collated and analyzed. Data are reported as median (mean ± SD), where appropriate. RESULTS:881 patients studied had a median age of 59 (57 ± 15.3) years and had a median Body Mass Index of 27 (28 ± 6.2) kg/m2. 65% were women. 343 (39%) had undergone a previous abdominal operation(s). Prior to LESS surgery, patients reported neutral body image scores and rated their overall appearance satisfaction as 40% (37% ± 30.7) on a Visual Analog Scale (VAS). 68% were unwilling to undergo LESS surgery if it involved more risk relative to traditional laparoscopy as safety was their number one concern. Postoperatively, patients reported a significant improvement in body image perception and safety was no longer their foremost concern. CONCLUSION:Preoperatively, patients are most concerned with safety (e.g. risk) with secondary concerns of cost and pain but they were less concerned with their appearance. Postoperatively, safety is much, much less of an issue (because it has been achieved) and appearance is more paramount with significant improvements in their self-assessed appearance. With LESS surgery patients indicate a high level of satisfaction with cosmesis.

Minimally invasive hepatectomy for benign and malignant liver lesions has gained popularity in the past decade due to improved perioperative outcomes when compared to conventional ‘open’ technique. We aim to investigate our initial experience of robotic hepatectomy undertaken in our hepatobiliary program. All patients undergoing robotic hepatectomy between 2013 and 2018 were prospectively followed. Data are presented as median (mean ± SD). A total of 80 patients underwent robotic hepatectomy within the study period. 60% of the patients were women, age of 63 (62.4 ± 14.1), body mass index of 28 (29.6 ± 9.4), ASA class of 2.5 (2.5 ± 0.6), and MELD score of 7 (8.2 ± 2.8). Size of resected lesion was 3.9 (4.6 ± 3) cm. Indications for resection were metastatic lesions (30%), hepatocellular carcinoma (28%), cholangiocarcinoma (7%), gallbladder cancer (5%), neuroendocrine tumors (4%), and benign lesions (26%). Formal hepatectomy (right or left) was performed in 30% of the patients. Operative time was 233 (267.2 ± 109.6) minutes, and estimated blood loss was 150 (265.7 ± 319.9) ml. Length of hospital stay was 3 (5.0 ± 4.6) days. One patient was converted to ‘open’ approach. 10 patients experienced postoperative complications. Readmissions within 30 days of hospital discharge were seen in eight patients. Our data support that robotic hepatectomy is safe and feasible, with favorable short-term outcomes and low conversion rate. Robotic technology extends the application of minimally invasive techniques in the field of hepatobiliary surgery.

Introduction: Robotic technology is increasingly utilized in complex abdominal operations, including hepatectomy.While minimally invasive techniques are associated with improved clinical outcomes.However, the robotic approach is perceived to result in significantly higher costs and financial burden to the hospital when compared to the traditional 'open' approach, limiting its application and adoption.Limited data is available in the published literature.In this study, we aimed to compare the cost of robotic versus open hepatectomy undertaken in our hepatobiliary program.Methods: A prospectively collected database of robotic and open hepatectomy from January 2014 through May 2019 was analyzed.Economic parameters consisting of total, variable, fixed direct, and fixed indirect costs for each resection were compared.Data was analyzed using a student paired t-test and ANOVA (GraphPad InStat ® , San Diego, CA).Analyses were considered statistically significant at 95% probability.Minor hepatectomy was defined as a resection of £ 2 liver segments.Results: 129 robotic and 52 open hepatectomies for hepatobiliary tumors were analyzed.Total operative time was 385 minutes for robotic and 361 minutes for open hepatectomy, (p=0.24).The median length of hospital stay was significantly shorter for patients undergoing robotic hepatectomy 4 versus 7 days, (p=0.001).Total costs for robotic and open hepatectomy were similar, $32,143 versus $39,049, respectively (p=0.078).Variable, fixed direct, and fixed indirect costs were not different for open and robotic hepatectomy (Table 1).Hospital charges for the robotic and open hepatectomy were $182,618 and $224,802, respectively (p=0.022).Payments received after the robotic and open hepatectomy were $33,774 and $52,849, respectively (p=0.002).When further divided into subgroups, the extent of robotic hepatectomy correlated with the total cost of each type of resection (p=0.001).Robotic minor hepatectomy resulted in the lowest total cost, $28,533.Yet, robotic nonanatomical left/right hepatectomy led to the highest total cost, $38,300.Conclusions: Robotic approach in liver surgery results in significantly shorter length of hospital stay.Despite the perception that the robotic platform results in significantly higher costs and financial burden to the hospital, the total costs between robotic and open hepatectomy were similar.The application of the robotic platform to treat hepatobiliary tumors does not increase the cost of healthcare.

Ross, Sharona B. MD, FACS; Craigg, Danielle MD; Bourdeau, Timothy J. BS; Spence, Janelle; Wecowski, Jack MD; Sucandy, Iswanto MD, FACS; Rosemurgy, Alexander MD, FACS Author Information

RPV; 4-Ligation RPV (tie and/or clips); 5-Partial parenchymal transection 50% preserving Middle Hepatic Vein (MHV) outflow.Postoperative imaging confirmed desired hypertrophy of the remnant liver volume within 9-11 days and the stage 2 ALPPS was carried out 14e16 days after stage 1.Three out of the four stage 2 cases were initiated with laparoscopy and intentionally converted to open extended right hepatectomy following a planned learning curve.Results: Case 1: 74F HCV s/p Harvoni, 6 cm HCC in segment 8, abutting the right hepatic and middle hepatic veins.Advanced liver fibrosis.Total liver volume 950 ml, volume of FLR 253 ml.Stage 1-Lap Partial ALPPS.Discharged POD#4.Repeat imaging POD#11, hypertrophied FLR 501ml.Stage 2-POD#16 Lap converted-to-open right extended hepatectomy.Discharged POD#6.Case 2: 58F PMHx of colon cancer, synchronous metastasis to the liver.FOLFOX+ Avastin.Total liver volume 910 ml.Right lobe 622 ml, 2 lesions occupy 58 ml.Left lobe 288 ml, 1 lesion occupies 23ml.Stage 1-Lap wedge LLS lesion+Lap Partial ALPPS.POD#2 Re-laparoscopy, bleeding-control hemostasis.Stage 2: preop imaging hypertrophied FLR 369 ml.POD#15-Open right hepatectomy + extended right colectomy.Discharged on POD#6.Case 3: 66M HCV s/p Harvoni, 3.5 cm HCC segment 8, abutting right hepatic vein, close to middle hepatic vein.Advanced liver fibrosis.Volume FLR 557 ml.Stage 1-Lap Partial ALPPS.Discharged POD#4.Repeated imaging POD#11, hypertrophied FLR 720 ml.Stage 2-POD#15, Lap converted-toopen right extended hepatectomy.Discharged POD#5.Case 4: 67M HCV s/p Harvoni) with 5 cm HCC segment 7, abutting right hepatic vein, close to middle hepatic vein.Advanced liver fibrosis.Volume FLR 583 ml.TACE followed 3 weeks later by Stage 1-Lap Partial ALPPS.Discharged POD#4.Repeated imaging POD#9.Hypertrophied FLR 976 ml.Stage 2-POD#14 Lap converted-toopen right extended hepatectomy.Complicated postop course, bleeding and infection.Reoperation/washout. Discharged POD#23.Conclusion: Each case is presented with a short video clip highlighting the technical steps of the Laparoscopic Partial-ALPPS during Stage 1, which were overall carried out without intraoperative difficulties and with satisfactory recovery and prompt discharge in all cases, while achieving the FLR hypertrophy within the expected timeframe.An additional video clip presents the laparoscopic findings during stage 2 prior to converting to open procedure, illustrating the amount of inflammation that challenged the laparoscopic completion of Stage 2 during this initial experience.

BACKGROUND: This study was undertaken to examine our outcomes after robotic pancreaticoduodenectomy and to compare our outcomes with predicted outcomes using the American College of Surgeons (ACS) NSQIP Surgical Risk Calculator and with outcomes reported through ACS NSQIP. METHODS: We prospectively followed 155 patients undergoing robotic pancreaticoduodenectomy. Outcomes were compared with predicted outcomes calculated using the ACS NSQIP Surgical Risk Calculator and with outcomes documented in ACS NSQIP for pancreaticoduodenectomy from 2012 to 2017. Median data are presented. RESULTS: Eighty-eight percent of our robotic pancreaticoduodenectomies were performed in 2015 to 2018. Predicted outcomes were like those reported in ACS NSQIP. Actual outcomes were superior to predicted outcomes and outcomes reported in ACS NSQIP for overall complications, serious complications, returned to operating room, surgical site infections, deep vein thrombosis, and length of stay. Seventeen percent had conversions to open operations, generally due to failure to progress or need for major vascular reconstruction; only 3 (3.5%) of the last 80 operations were converted to open. Robotic operations took 423 minutes; estimated blood loss was 200 mL. Biliary fistulas occurred in 5% and pancreatic fistulas occurred in 5%. Six percent of patients died perioperatively; 5 patients died due to cardiac deterioration and 4 (3.1%) patients died after pancreaticoduodenectomy completed robotically. CONCLUSIONS: Our patients were not a select group, they were like those reported in ACS NSQIP. Their outcomes after robotic pancreaticoduodenectomy were like or better than predicted outcomes or national data. Our mortality was high because of preoperative ill health (eg renal failure) and cardiac risk. Although we believe our results will continue to improve, our current data document the salutary benefits of minimally invasive robotic pancreaticoduodenectomy. (C) 2019 Published by Elsevier Inc. on behalf of the American College of Surgeons.