Summary

Robotic Donor Hepatectomy is emerging as an excellent alternative to open donor transplant which were the norm till a few years ago. The precision, dexterity and improved visualization available with Robotic Surgery makes it easy for surgeons to complete the transplant with minimal hassle. The landscape of transplantation is evolving rapidly. Robotic systems and surgical instruments used in these transplants are becoming more sophisticated. This reduces the learning curve for new surgeons adopting Robotics in transplantation. In this article, we will learn more.

Introduction

In recent years, there has been a spurt in liver ailments. Incidences of liver cirrhosis is on the rise due to prevalence of non-alcoholic fatty liver disease, which is again due to obesity, poor dietary choices, diabetes, dyslipidaemia and a sedentary lifestyle. Sadly, there is also a rise in alcoholic liver disease, which is due to increased alcohol-consumption for social and recreational purposes. In addition to fatty liver disease, there are various other conditions that can damage the liver. As the damage continues, it progresses towards Liver failure. Again, Liver failure may happen quickly and suddenly (acute) or develop gradually over time (chronic).

Major causes of liver damage:

• Hepatitis A, B and C virus
• Non-alcoholic fatty liver disease: In this, fat starts accumulating in the liver, causing inflammation of the liver cells and eventually damage to them.
• Alcoholic liver disease, and its consequence – cirrhosis of the liver
• Genetic diseases that affect the liver such as hemochromatosis (excessive build-up of iron in the liver) and Wilson’s disease (excessive build-up of copper in the liver)
• Diseases that affect the bile ducts (which are the tubes that carry bile from the liver). This includes biliary atresia and primary biliary cirrhosis.
• Primary Sclerosing Cholangitis (bile ducts become inflamed, scarred, narrowed and blocked)
• Hepatocellular carcinoma or Liver cancer
• Damage caused by drug overdose

Although the above causes will be treated using medication, in some people, the damage progresses rapidly. The body starts losing its regenerative capacity to repair the damage and heal the organ. Once the damage has crossed the point of repair, a liver transplantation is the only option left to save the patient.

Also Read: ALL YOU NEED TO KNOW ABOUT LIVER TRANSPLANTATION

Types of Liver Transplant

• Deceased donor liver transplant (DDLT): Here, a healthy liver is harvested from a deceased person (also called cadaver) who is brain-dead due to various conditions, or an accident. Unfortunately, this comprises just 7 to 8% of all transplant cases, due to cultural and social beliefs or dogmas around organ donation. This means, there is always a shortfall of organs in India, Middle-east and some other Asian countries.
• Live donor liver transplant (LDLT): The liver has a unique capacity to regrow or regenerate itself when a part of it is taken away. Further, the liver can function fine when just one third of it is available and fully-healthy. This has made live donor transplant an excellent option. A suitable matching donor from the family can donate a part of their liver to the patient. The diseased liver is removed from the patient’s body, the healthy liver-segment from the donor is transplanted and all connections made again. In 3 to 6 months’ time (depending on age and general health), the liver in both donor and recipient would have grown to its full size.

The process of transplantation is similar in both DLT and LDLT. The bile ducts, hepatic artery, and hepatic portal vein in the person with diseased liver are carefully disconnected. After the new liver (or liver-segment) is transplanted into the recipient’s body, all these connections are made again, after which the new liver starts working immediately.

Robotic vs Open Hepatectomy (Donor Liver Surgery)

Open liver donor operation which was the norm in the past comes with disadvantages like pain, infections, slower recovery, noticeable scars, incisional hernia and long hospital stays. All these drawbacks are overcome in Robotic Surgery.

Chronologically, before the advent of Robotic Surgery, we have Laparoscopic transplants, which is a Minimally Invasive process, that are still used for the cost-benefit compared to Robotic Surgery. However, this too comes with its own, technical limitations.

• Suboptimal instrumentation: The kind of instruments that can be used in a laparoscopic transplant, the flexibility or range of motion they offer, are mediocre, which leaves a lot of room for improvement.
• Challenging ergonomics: The channels used to introduce the surgical instruments are rigid sticks, which makes operating the instruments difficult
• Long learning curve: As a result of the above limitations, it requires highly-trained and experienced surgeons to do the procedure, which restricts it to a few centres.
• Significant scars: Compared to robotic surgery, the scars are a little more visible
• Longer hospital stays: May be not as long as for open surgery, but more than what happens with Robotic Surgery.

In contrast, the da Vinci Surgical System (from Intuitive Surgical) that is used for Living Donor Hepatectomy ( LDLT) is very sophisticated and offers superior features that are a boon in the surgeon’s hands.

• Intuitive translation of control from instrument handle to the tip: The transfer of control from instrument handle (the robotic arm basically) and the surgical instrument at the tip of the arm is smooth, stable, and efficient, without any loss.
• Superior 3D Visualization: A stable camera platform and high-resolution (10x) 3D images provided by the camera make it easy to see rare images which helps the surgeon make better decisions, and perform effective interventions.
• Scaling: this refers to the range of motion. The robotic arms can move smoothly over long distances and large angles, thereby increasing the scale of its operability.
• Tremor filtering: a tired surgeon’s hands can tremble (tremor) while doing the procedure. Tremors and vibrations are all eliminated from the robotic instruments.
• Coaxial alignment of eyes, hand, and tool tip images: There is no distortion of vision and hence the need to realign one’s position or instruments, which can happen with laparoscopic surgeries.
• Endo-Wrist with a 360-degree range of motion: The end of the arm or the wrist is a powerful tool in itself called the Endo-Wrist. It can rotate 360 degrees, this way, the procedure can be very precise.
• Comfortable, ergonomically-designed operating position: The main surgeon sits on a computer console in a position that makes it easy for him/her to see the computer as well as the operating field. Minor observations if any can be communicated by assisting surgeons in the OT.
• The possibility of remote-site surgery: Robotic surgery opens the doors for Telesurgery which eliminates the need for the surgeon to be physically present.

Also Read: Success of Liver Transplantation, post-transplant Dos and Don’ts

How is the Transplant done?

Before

Preparing for the transplant is similar to that for any surgery. The below guidelines will apply both for the live donor and the recipient.

• After a thorough medical checkup, the schedule for the transplant will be fixed.
• The patient must stop smoking and taking any form of medication a week before the surgery.
• Patient must not consume anything after midnight on the day preceding surgery.
• On the day of the surgery, he/she will be first sedated mildly to help calm the nerves.
• Vital parameters will be checked and once stable, the patient will be wheeled into the OT with the Robotic System in close proximity.
• He/she will be administered general anaesthesia, and the patient will lose consciousness.
• An IV line will be started in one arm, to administer fluids and medication.
• A tube will be inserted into the throat all the way to the lungs to help him/her breathe.
• All vitals will be monitored throughout the procedure.

During

A similar robotic procedure will be done beforehand to harness the liver-segment and gall-bladder in case of LDLT, or the whole liver and gall-bladder in case of DLT. The harnessed liver or liver-segment and gall-bladder, will be brought into the OT where transplant into the recipient will happen.

• The surgical team will clean the surgery-area in the recipient’s body, with an antiseptic solution.
• The necessary incisions will be made, the robotic arms will be inserted.
• The bile ducts, hepatic artery and hepatic portal vein will be carefully disconnected from the diseased liver and gall-bladder.
• The diseased liver and gall-bladder will be removed and pulled out of the body.
• The new liver and gall-bladder will be inserted in position.
• The bile ducts, hepatic artery and hepatic portal vein will be carefully connected to the new liver and gall-bladder.
• The incision will be closed with stitches and a dressing applied to the wound.

After

• The patient will be discharged once all vitals all stabilized (in 2-3 days’ time).
• He/she will be given various dos and don’ts to follow, for quick recovery.

The future of Robotic Hepatectomy

Robotic Hepatectomy, or Robotic Liver Transplants have a bright future, and are an evolving domain. According to some leading doctors of the world, a large percentage of liver transplants in the future will be done robotically. Further,

• Artificial Intelligence (AI) and Machine Learning (ML) algorithms will be harnessed to create the perfect match between the list of available donors and cadavers, with the current list of patients requiring transplant. This will increase the success rate of these transplants.
• We could also see experiments with artificial livers (mad-made equipment that mimic the liver’s functions) and livers from animals such as cattle or sheep, being used for transplantation in the next 1 or 2 decades.
• Most transplant recipients need to take tolerance-inducing drugs all their life, or for a long duration to prevent the body from rejecting the transplant. In the future, more superior drugs will emerge that will require them to be administered for short periods of time (like a few months).

Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai, Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.

Chennai – Alwarpet/Vadapalani 044 4000 6000 • Trichy – Cantonment – 0431 4077777 • Trichy – Heartcity – 0431 4003500 • Trichy – Tennur – 0431 4022555 • Hosur – 04344 272727 • Salem – 0427 2677777 • Tirunelveli – 0462 4006000 • Bengaluru – 080 6801 6801

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