Xiang-Yan Liu ,Yun-Yang Xu ,Ze Xiang ,Shu-Sen Zheng

a Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou 310015, China

b Zhejiang University School of Medicine, Hangzhou 310009, China

TotheEditor:

We read with great interest the article by Schulze et al.entitled “Robotic surgery and liver transplantation: A single-center experience of 501 robotic donor hepatectomies” [1].It is the first single-center report including over 500 fully robotic donor hepatectomies.For the donors,the overall complication rate was 6.4%(n=32).Postoperative self-limiting bleeding (0.4%) and bile leakage from the resection plane (1.8%) were rare,none of which required further action.For recipients,the three-year actual overall recipient survival was 91.4%.Retransplantation rate was low (1.2%)as were the rates of biliary (5.6%) and vascular (4.4%) complications.Through this study,the authors demonstrated that robotic surgery is relatively mature in donor hepatectomies.

Robotic liver surgery is a minimally invasive technique that uses a robotic system to perform complex operations on the liver,which has several incomparable advantages: (1) visualization with amplification;(2) ergonomics with tremor-free instrumental movements which have a much wider range of angulation;(3) precise dissection capabilities;(4) more expeditious suturing abilities [2].Furthermore,the 3D and magnification view makes the technique excellent in distinguishing the right plane of transection,vascular and biliary anatomy,thus significantly reducing the rate of vascular injury.The degree of freedom of the robotic arm can also better control sudden bleeding [3].Thanks to these advantages,there have been some achievements in robotic liver surgery.In 2017,Liao et al.published the first successful case report of robot assisted living donor left lateral sectionectomy (LLS) for a 7-month-old boy affected by congenital biliary atresia [4].In 2022,Rela et al.successfully performed robotic monosegment donor hepatectomy (RMDH)on a 14-month-old girl with extrahepatic biliary atresia,which was the first RMDH for pediatric liver transplantation [5].Just as the study of Schulze et al.,robotic surgery has been a breakthrough in liver surgeries.

Although robotic surgery has many advantages,controversy still exists.The major controversy regards mainly cost,safety of biliary transection and vessel hemorrhage [3].To improve robotic surgery,we should first ensure that surgeons undergo rigorous and specialized training in robotic liver surgery.Besides,we recommend hospitals invest in the latest robotic surgical systems,like the da Vinci Surgical System,which offers improved precision and ergonomics.The latest technology artificial intelligence (AI) should also be applied.We believe that the application of AI in 3D visualization,virtual simulation,augmented reality and deep learning may assist robotic surgery.

Acknowledgments

None.

CRediT authorship contribution statement

Xiang-Yan Liu:Writing– original draft.Yun-Yang Xu:Data curation.Ze Xiang:Data curation.Shu-Sen Zheng:Conceptualization,Writing– review &editing.

Funding

None.

Ethical approval

Not needed.

Competing interest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.