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      IWATE criteria are associated with perioperative outcomes in robotic hepatectomy: a retrospective review of 225 resections

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          Abstract

          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.

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          Most cited references24

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          Ultrasonically guided subsegmentectomy.

          A new operative procedure for systematic subsegmentectomy guided by ultrasound has been described. This operation consists of operative sonography, ultrasonically guided puncture and injection of dye and hemihepatic blood occlusion. Systematic subsegmentectomy was performed upon 57 patients without operative mortality. The cumulative one year survival rate of 35 patients with hepatocellular carcinoma who underwent operation at our hospital was 80.3 per cent. The two and three year survival rates were 63.3 and 52.6 per cent, respectively.
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            A novel difficulty scoring system for laparoscopic liver resection.

            Early on, laparoscopic liver resection (LLR) was limited to partial resection, but major LLR is no longer rare. A difficulty scoring system is required to guide surgeons in advancing from simple to highly technical laparoscopic resections. Subjects were 90 patients who had undergone pure LLR at three medical institutions (30 patients/institution) from January 2011 to April 2014. Surgical difficulty was assessed by the operator using an index of 1-10 with the following divisions: 1-3 low difficulty, 4-6 intermediate difficulty, and 7-10 high difficulty. Weighted kappa statistic was used to calculate the concordance between the operators' and reviewers' (expert surgeon) difficulty index. Inter-rater agreement (weighted kappa statistic) between the operators' and reviewers' assessments was 0.89 with the three-level difficulty index and 0.80 with the 10-level difficulty index. A 10-level difficulty index by linear modeling based on clinical information revealed a weighted kappa statistic of 0.72 and that scored by the extent of liver resection, tumor location, tumor size, liver function, and tumor proximity to major vessels revealed a weighted kappa statistic of 0.68. We proposed a new scoring system to predict difficulty of various LLRs preoperatively. The calculated score well reflected difficulty.
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              What has changed after the Morioka consensus conference 2014 on laparoscopic liver resection?

              The 2(nd) International Consensus Conference on Laparoscopic Liver Resection (ICCLLR) was held 4(th)-6(th) October, 2014, in Morioka, Japan. The level of evidence appears to be low in the field of laparoscopic liver resection (LLR) to create strong recommendations. Therefore, an independent jury-based consensus model was applied to better define the current role of LLR and to develop internationally accepted recommendations. The three-day conference was very intense with full of insightful discussions on assessment of LLR and its future directions. The jury drew the statements based on the presentations and documents prepared by the expert. LLR is theoretically superior to open liver resection (OLR) because the laparoscope allows better exposure with a magnified view, and the pneumoperitoneum pressure reduces hepatic vein bleeding from the cut surface. During the ICCLLR, we shared these theoretical advantages in LLR and the conceptual change of liver resection. After the ICCLLR, a couple of important studies have been published to prove this theoretical superiority of LLR over OLR in short-term outcomes without deteriorating long-term outcomes. Another new concept was proposed at the ICCLLR: parenchyma sparing (limited) anatomical resection. Review of the literature supports anatomical resection with parenchyma sparing strategy for LLR irrespective of hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM). Just after the ICCLLR, sensational news of clustered mortality after LLR was reported in the Japanese media and they impacted on daily practice of LLR in Japan. The most important message from the ICCLLR is to protect patients from this new surgical procedure. The ICCLLR recommended three actions for the protection of patients: (I) prospective reporting registry for transparency; (II) a difficulty scoring system to select patients; (III) creation of a formal structure of education. The online prospective registry system including items to calculate the difficulty score has been created in Japan after the ICCLLR for the safe development of LLR.
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                Author and article information

                Contributors
                jopark@uw.edu
                Journal
                Surg Endosc
                Surg Endosc
                Surgical Endoscopy
                Springer US (New York )
                0930-2794
                1432-2218
                19 February 2021
                19 February 2021
                2022
                : 36
                : 2
                : 889-895
                Affiliations
                [1 ]GRID grid.34477.33, ISNI 0000000122986657, 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
                [2 ]GRID grid.34477.33, ISNI 0000000122986657, Center for Advanced Minimally Invasive Liver Oncologic Therapies (CAMILOT), , University of Washington, ; Seattle, WA 98195 USA
                [3 ]GRID grid.412623.0, ISNI 0000 0000 8535 6057, Hepatobiliary Surgical Oncology, Department of Surgery, , University of Washington Medical Center, ; 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA 98195-6410 USA
                Author information
                http://orcid.org/0000-0001-6939-1255
                Article
                8345
                10.1007/s00464-021-08345-w
                8758630
                33608766
                46b9fbfc-4078-41e3-88af-2def84c2ff73
                © The Author(s) 2021

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 19 September 2020
                : 27 January 2021
                Categories
                Article
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                © Springer Science+Business Media, LLC, part of Springer Nature 2022

                Surgery
                robotic hepatectomy,minimally invasive surgery,iwate criteria,robotic surgery
                Surgery
                robotic hepatectomy, minimally invasive surgery, iwate criteria, robotic surgery

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