Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA.
Center for Advanced Minimally Invasive Liver Oncologic Therapies (CAMILOT), University of Washington, Seattle, WA, 98195, USA.
Surg Endosc. 2022 Feb;36(2):889-895. doi: 10.1007/s00464-021-08345-w. Epub 2021 Feb 19.
BACKGROUND: Robotic hepatectomy (RH) is increasingly utilized for minor and major liver resections. The IWATE criteria were developed to classify minimally invasive liver resections by difficulty. The objective of this study was to apply the IWATE criteria in RH and to describe perioperative and oncologic outcomes of RH over the last decade at our institution. METHODS: Perioperative and oncologic outcomes of patients who underwent RH between 2011 and 2019 were retrospectively collected. The difficulty level of each operation was assessed using the IWATE criteria, and outcomes were compared at each level. Univariate linear regression was performed to characterize the relationship between IWATE criteria and perioperative outcomes (OR time, EBL, and LOS), and a multivariable model was also developed to address potential confounding by patient characteristics (age, sex, BMI, prior abdominal surgery, ASA class, and simultaneous non-hepatectomy operation). RESULTS: Two hundred and twenty-five RH were performed. Median IWATE criteria for RH were 6 (IQR 5-9), with low, intermediate, advanced, and expert resections accounting for 23% (n = 51), 34% (n = 77), 32% (n = 72), and 11% (n = 25) of resections, respectively. The majority of resections were parenchymal-sparing approaches, including anatomic segmentectomies and non-anatomic partial resections. 30-day complication rate was 14%, conversion to open surgery occurred in 9 patients (4%), and there were no deaths within 30 days postoperatively. In the univariate linear regression analysis, IWATE criteria were positively associated with OR time, EBL, and LOS. In the multivariable model, IWATE criteria were independently associated with greater OR time, EBL, and LOS. Two-year overall survival for hepatocellular carcinoma and intrahepatic cholangiocarcinoma was 94% and 50%, respectively. CONCLUSION: In conclusion, the IWATE criteria are associated with surgical outcomes after RH. This series highlights the utility of RH for difficult hepatic resections, particularly parenchymal-sparing resections in the posterosuperior sector, extending the indication of minimally invasive hepatectomy in experienced hands and potentially offering select patients an alternative to open hepatectomy or other less definitive liver-directed treatment options.
背景：机器人肝切除术（RH）越来越多地用于小肝癌和大肝癌的切除术。IWATE 标准是为了通过难度来对微创肝切除术进行分类。本研究的目的是将 IWATE 标准应用于 RH，并描述我院过去十年 RH 的围手术期和肿瘤学结果。
方法：回顾性收集 2011 年至 2019 年接受 RH 的患者的围手术期和肿瘤学结果。使用 IWATE 标准评估每个手术的难度水平，并比较每个水平的结果。采用单变量线性回归分析 IWATE 标准与围手术期结果（手术时间、出血量和住院时间）的关系，并建立多变量模型以解决患者特征（年龄、性别、BMI、既往腹部手术史、ASA 分级和同时非肝切除术）的潜在混杂因素。
结果：共进行了 225 例 RH。RH 的中位 IWATE 标准为 6（IQR 5-9），低、中、高、专家切除分别占 23%（n=51）、34%（n=77）、32%（n=72）和 11%（n=25）。大多数切除术是保留肝实质的方法，包括解剖性肝段切除术和非解剖性部分切除术。30 天并发症发生率为 14%，9 例患者转为开腹手术（4%），术后 30 天内无死亡。在单变量线性回归分析中，IWATE 标准与手术时间、出血量和住院时间呈正相关。在多变量模型中，IWATE 标准与更长的手术时间、出血量和住院时间独立相关。肝细胞癌和肝内胆管细胞癌的 2 年总生存率分别为 94%和 50%。
结论：总之，IWATE 标准与 RH 后的手术结果相关。本系列强调了 RH 在困难肝切除术，特别是后上叶保留肝实质的切除术的应用，为经验丰富的医生扩大了微创肝切除术的适应证，并为选择的患者提供了开放肝切除术或其他非确定性肝定向治疗方法的替代方案。
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