Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
488
Fig. 33.20 Identication
of intrathoracic mass and
inferior dissection plane.
Cephalad and caudad
labeled for orientation
Fig. 33.21 Identication
of a tumor-feeding blood
vessel
B. Williams and M. Sancheti
aorta using robotic arm 1 and the assistant retracting the mass posteriorly
(Fig.33.24). A plane of dissection can be created easily along a rib when identied
(Fig.33.25). After the last tumor attachments are ligated in the superior and medial
aspect of the dissection, the Endo Catch bag was placed into the assistant port with
subsequent removal of the specimen after the trocar incision was enlarged
(Fig.33.26). Pathology revealed a schwannoma.
33 Mediastinal Procedures
Fig. 33.22 Identication,
dissection, and clipping of
an intercostal artery
feeding the tumor. Red
arrow points to the
intercostal artery off the
aorta
Fig. 33.23 Posterior and
lateral dissection of the
mass. The robotic arm
retracts the mass anteriorly
489
490
Fig. 33.24 Anterior and
medial dissection of the
mass. Aorta and mass are
labeled. The robotic arm
retracts the aorta anteriorly.
The suction irrigator
retracts the tumor
posteriorly
Fig. 33.25 Identication
of a rib as a marker for the
posterior dissection plane
B. Williams and M. Sancheti
33 Mediastinal Procedures
Fig. 33.26 Removal of
the specimen using the
Endo Catch bag through
the access port
491
Summary
Robotic assistance is useful for navigating and dissecting the mediastinal space. In
comparison to traditional open techniques, minimally invasive approaches have
been shown to have superior short-term outcomes and comparable oncologic outcomes when applicable. Robotic-assisted mediastinal surgery has further enhanced
existing VATS techniques given its three-dimensional visualization, improved dexterity with articulating EndoWrist technology, and elimination of tremor. Future
advances such as haptic feedback would further increase the value of robotic assistance in delicate mediastinal operations. The most common indicated procedures
were presented in detail for the anterior, middle, and posterior mediastinal lesions.
The principles learned from these examples may be applied to a wide variety of
mediastinal pathologies. Continued research on the efcacy of robotic-assisted
mediastinal resections is needed as well as ongoing development of robotic surgical
techniques and technology.
References
1. Manoly I, etal. Early and mid-term outcomes of trans-sternal and video-assisted thoracoscopic
surgery for thymoma. Eur J Cardiothorac Surg. 2014;45(6):e187–93.
2. Straughan DM, Fontaine JP, Toloza EM.Robotic-assisted videothoracoscopic mediastinal surgery. Cancer Control. 2015;22(3):326–30.
3. Demmy TL, etal. Multicenter VATS experience with mediastinal tumors. Ann Thorac Surg.
1998;66(1):187–92.
492
4. Ye B, etal. Video-assisted thoracoscopic surgery versus robotic-assisted thoracoscopic surgery
in the surgical treatment of Masaoka stage I thymoma. World J Surg Oncol. 2013;11:157.
5. Yang CJ, etal. A national analysis of open versus minimally invasive thymectomy for stage I
to III thymoma. J Thorac Cardiovasc Surg. 2020;160(2):555–67.
6. Juanpere S, et al. A diagnostic approach to the mediastinal masses. Insights Imaging.
2013;4(1):29–52.
7. Asaf BB, Kumar A, Vijay CL. Robotic excision of paraesophageal bronchogenic cyst in a
9-year-old child. J Indian Assoc Pediatr Surg. 2015;20(4):191–3.
8. Toker A, etal. Resection of a bronchogenic cyst in the rst decade of life with robotic surgery.
Interact Cardiovasc Thorac Surg. 2014;19(2):321–3.
9. Bacchetta MD, etal. Resection of a symptomatic pericardial cyst using the computer-enhanced
da Vinci Surgical System. Ann Thorac Surg. 2003;75(6):1953–5.
10. Ribet ME, Copin MC, Gosselin B. Bronchogenic cysts of the mediastinum. J Thorac
Cardiovasc Surg. 1995;109(5):1003–10.
B. Williams and M. Sancheti
Liver Transplantation
34
YeeLeeCheah, GiHongChoi, YoungRokChoi,
andKwangWoongLee
Introduction
Living donor liver transplantation (LDLT) consists of two simultaneous operations
where (1) a healthy living person donates a portion of their liver to a recipient on the
liver transplantation waiting list and (2) the recipient has their diseased liver
removed and the donated graft implanted. LDLT is possible due to the regenerative
properties of the liver; in ideal situations, the remnant liver in the donor and the
recipient may regrow to volumes close to 100% of original volume 1year after
surgery [1, 2].
The rst successful living donor liver transplantation was performed in 1989,
where the left lateral section of a mother was transplanted into her 18-month-old
child with biliary atresia [3]. The selection of the lobe or section to be donated is the
smallest portion of the liver that meets the requirement of the recipient (most
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 86927- 3_34.
Y. L. Cheah (*)
JC Walter Jr Transplant Center, Sherrie and Alan Conover Center for Liver Disease and
Transplantation, Houston Methodist Hospital, Houston, TX, USA
Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
e-mail: ycheah@houstonmethodist.org
G. H. Choi
Division of Hepato-biliary and Pancreatic Surgery, Yonsei University College of Medicine,
Seoul, South Korea
Y. Choi · K. W. Lee
Division of HBP Surgery, Department of Surgery, Seoul National University College of
Medicine, Seoul, South Korea
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_34
493
494
Resection for living donation vs resection for liver pathology
Y. L. Cheah et al.
common metric used is the graft to body weight ratio where the most conventional
limit is ≥0.8) [4].
The majority of LDLT cases globally are performed in Asia, whereas only 658
out of 10,660 (6.2%) cases of liver transplantation in the United States were from
living donor grafts in 2023 [5, 6]. Due to the technically complex nature of both the
donor and recipient operations, these procedures are performed at highly specialized centers. Each potential living donor and recipient undergo an extensive evaluation process to determine suitability for LDLT.
In the United States, recipients who undergo living donor liver transplantation
have improved survival rates at 1year compared those who received grafts from
brain-dead donors [7]. They also return to work earlier and have higher rates of
returning to work for income. The availability of a living donor eliminates their
need to wait for deterioration of their liver function to increase their chances of
obtaining a deceased donor graft.
Robotic Donor Hepatectomy
The most common types of donor hepatectomy are right lobe, left lobe, and left
lateral section resections. Most centers accept 30% as the minimum future liver
remnant volume in the donor to allow for adequate regeneration. The differences
between a donor hepatectomy and a hepatectomy for pathology are shown in
Fig.34.1.
Three-dimensional reconstruction of a potential donor’s liver imaging is useful
to detect (1) volumes of graft and remnant and (2) aberrant vascular anatomy, (3)
gauge the length of hepatic artery and portal vein that will be available for recipient
anastomosis and (4) the number of bile ducts that will need to be anastomosed, and
Living Donor Hepatectomy
•Resected lobe preserved for recipient implantation
• Adequate size for recipient GBWR ≥ 0.8
•Remnant has to be adequate for donor
•Dissection of HA, PV and HV branches to lobe
• Accurate transection line reduces bleeding, aims for
graft & remnant volumes as predicted
•Ideally NO inflow or outflow control during transection
• Segmental HVs may need preservation and
reconstruction
• Careful extraction of graft in a timely manner to reduce
warm ischemic time
•Preoperative workup more extensive
•3D liver anatomy reconstruction
•Operating on a healthy person who wants to save
recipient’s life
Fig. 34.1 Differences between donor hepatectomy and hepatectomy for pathology
Hepatectomy for pathology
• Resected lobe goes to pathology
•Remnant size important
•Option of Glissonian approach
•Margins important in transection
• Both inflow and outflow can be taken
prior to transection
• Segmental HVs ligated without issues
•No time or physical constraints to
extraction of specimen
•Standard workup
•Patient needs resection for own cure and
survival
34 Liver Transplantation
Fig. 34.2 Threedimensional reconstruction
of potential living donor
liver with inow and
outow vessels and
proposed transection line.
(Image courtesy of © 2024
MeVis Medical Solutions
AG, Bremen, Germany)
495
(5) evaluate segmental hepatic venous drainage of the lobe to be donated (particularly important for right lobe grafts) to determine the need for reconstruction prior
to implantation. Figure34.2 demonstrates an example of a 3-D reconstruction of a
donor liver created from a CT and MRI of the abdomen.
Donor safety is paramount in any LDLT, and informed consent is obtained prior
to evaluation and surgery. Risks of a donor hepatectomy include but are not limited
to bleeding, biliary complications, infectious complications, post-hepatectomy liver
failure, and thromboembolic disease. Overall reported complication rates were
25–30% in right donor hepatectomy and 15–20% in left-sided grafts [8–10].
Mortality rates for LDLT in the United States has been quoted at up to 0.5% for
right lobe donors and 0.1% for left-sided donors, though overall death rates appeared
to have decreased in the last decade.
As living donors are healthy individuals willing to accept risks in order to save
another’s life, their well-being should be optimized. About 15% of donors reported
donation-related issues including hernia (22%) and scar or adhesion problems (9%)
and 22% could not perform physical activities as well as they did preoperatively,
mainly due to limitations of abdominal wall strength. In a post-donation quality-oflife analysis, incisional discomfort was the most common symptom reported [11,
12]. This has spurred efforts by living donor teams to explore minimally invasive
approaches to donor hepatectomy.
The rst laparoscopic donor left lateral sectionectomy was reported in 2002 and
the rst laparoscopic right donor hepatectomy in 2013. The largest multicenter
series from Korea reported a 10% overall and 4.9% serious complication rates. The
emergence of the robotic approach in liver surgery prompted expansion of this
modality in donor hepatectomy; the rst robotic right donor hepatectomy was
reported in 2012 (Chicago) [13], and rst series in 2016 (Taiwan) [14]. Since then,
larger series have been reported by a handful of highly specialized centers [15, 16].
Reported overall and serious complications rates have been better or comparable to
open series.
496
Y. L. Cheah et al.
Patient Selection
After completion of the standard evaluation process, determination of the suitability
of the robotic approach is inuenced by the experience of the surgical team and the
anatomy of the graft. At the beginning of a center’s experience with a robotic
approach for donor hepatectomy, avoiding donors with previous upper abdominal
laparotomy may be prudent. Straightforward graft anatomy should be selected (single hepatic artery and portal vein and few segmental veins requiring reconstruction)
for right donor hepatectomy. Once the learning curve is achieved, these criteria may
be relaxed. Liver anesthesia management should integrate enhanced recovery protocols in uid management and low central venous pressure. Most living donors,
who tend to be younger and healthy individuals, qualify for many aspects of an
enhanced recovery protocol [17].
Patient Positioning andPort Placement
Positioning
Patients are placed in a split-leg position to enable the bedside surgeon to stand
between the patient’s legs (Fig.34.3). One arm may be abducted to enable access by
Fig. 34.3 Operating room setup for robotic donor hepatectomy
ab
34 Liver Transplantation
497
anesthesiologist to intra-arterial and intravenous cannulas during the operation. All
pressure points are padded, and the patient is secured to the operating table at the
hip and chest areas. Both legs are secured to the leg extensions and footrests are
used to prevent slippage during positioning. Once all ports are placed, the patient is
positioned at a 10-degree reverse Trendelenburg, and a slight right-side up rotation
for donor right hepatectomy.
Port Placement
Recommended port placements for right versus left donor hepatectomy or left lateral donor sectionectomy are shown in Fig.34.4a, b, respectively. The third arm is
a right-handed instrument. Two laparoscopic assistant ports (12mm and 5mm) are
inserted in the lower abdomen; their tracts are slanted toward the upper abdominal
surgery. The grafts are retrieved from a Pfannenstiel incision. Pneumoperitoneum
pressure is kept at or below 12mm Hg.
Instruments
Basic Robotic Instruments forDissection andMobilization
1. Maryland bipolar (+ electrocautery)
2. Camera
3. Scissors (+ electrocautery)
4. Cadiere or ProGrasp forceps
Fig. 34.4 (a) Port positions for right donor hepatectomy (b) Port positions for left or left lateral
donor hepatectomy