Liver Malignancies in Segment VII: The Role of Robot-assisted Surgery

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To the Editor:
Lim and colleagues 1 have recently published an extremely interesting article, titled “Surgical Indications and Procedures for Resection of Hepatic Malignancies Confined to Segment VII.” The article was read with great interest because scant data exist on the current surgical practice in the treatment of such lesions, and the authors are to be congratulated on their work, which includes a large series of resections of liver malignancies in segment VII. Of note, despite their large experience, in the last 2 years, they included only 8 cases of minimally invasive resections (of which only a percentage of cases were fully laparoscopically performed) that were limited to excise peripheral lesions. Indeed, although substantive advances have been made with regard to minimally invasive surgery for liver malignancies, resection in posterosuperior segments is still considered a relative limitation of laparoscopy 2–5 : this surgery requires angulated or curved lines of section and rigid laparoscopic tools, with their few degrees of freedom, make the procedure highly demanding. 4,6,7
Our interest in reading this article relates also to the fact that in our experience with liver surgery, both formal hemihepatectomies and limited excisions such as segmentectomies or wedges are usually performed robotically, and we also had the opportunity to treat a number of both primary and secondary malignancies located in segments VII and VIII. With resection of such lesions in particular, we do believe that surgery may benefit greatly from robotics. Several technical issues intrinsic to conventional laparoscopic techniques have been partially addressed by robotic systems, which permit not only 3-dimensional imaging but also augmented surgical dexterity that affords excellent control of accurate dissections. Moreover, a fully robot-integrated ultrasonography, which currently affords maneuverability in all robotic degrees of freedom, permits better localization of the lesions to be excised and precise visualization of neighboring vascular and biliary structures. Both the operative field and the ultrasound image are simultaneously displayed in real time above the surgeon's goggles: this allows a precise understanding of anatomy and vascularity and more uninterrupted dissections. All these features also permit easier management of possible intraoperative complications such as major bleedings or bowel injuries, with a lower rate of conversion to laparotomy. 8 Notably, the surgeon is provided with a full range of motion, with a global range of movements within the abdomen that is similar to that of open surgery: this is an enormous advantage, especially when angulated or curved lines of section are needed and the parenchyma-sparing principle is to be followed. In this regard, also in such instances, robot-assisted surgery may also reduce the high proportions of major hepatectomies reported by some series, as has been noted by several authors. 7,9,10
We congratulate the authors on their valuable analysis, and we do believe that liver surgery represents one of the fields in which robotics may greatly improve and extend the range of application of minimally invasive surgery, which, accordingly, should not be confined to subglissonian, peripheral malignancies even when the lesions to be resected are located in the posterosuperior segments.
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