Robotic Liver Transplant Surgery - Procedure, Benefits & Result

Robotic surgery is a surgical procedure carried out by mechanical arms which are controlled by the surgeon. These mechanical arms use surgical instruments and a camera to avoid the need for making large incisions. 

Anatomy and Physiology

1. The liver is responsible for processing blood and breaking down the nutrients for the rest of the body. 
2. It is reddish-brown and weighs about 3 pounds. 
3. It is located in the upper right portion of the abdominal cavity, beneath the diaphragm, and above the stomach, right kidney, and intestines. 
4. Oxygenated blood flows to the liver from the hepatic artery.
5. Nutrient-rich blood flows to the liver from the hepatic portal vein.
6. It consists of 2 lobes, each made up of 8 segments, consisting of 1,000 lobules. 
7. The small ducts connect with the larger ducts to form the common hepatic duct, which transports the bile made by the liver to the gallbladder and duodenum via the common bile duct. 

Robotic liver surgery is performed for people suffering from liver failure. Robotic liver surgery is feasible for both primary and secondary liver malignancies. Surgeons can perform both minor and major liver resections robotically. 

Role of Robots in Liver Surgery

Robotic liver surgery allows the surgeon to perform advanced procedures with improved precision and a three-dimensional view of the surgical site. Moreover, it is an effective alternative to laparoscopic surgery for malignant and benign liver lesions. It overcomes some of the limitations of both laparoscopic and open surgery. The advantages of robotic liver surgery over laparoscopic surgery include:

1. Improved optic visualisation
2. Better operative agility
3. Ease of dissection and suturing

There are several advantages of robotic liver surgeries over traditional techniques. These advantages include:

1. Less pain and blood loss
2. Fewer complications, including a lower chance of surgical site infections
3. Quick recovery
4. Less noticeable scars
5. Shorter hospital stay

However, robotic surgery is not an ideal option for everyone. You can talk to your healthcare provider to discuss the benefits and risks of the procedure. 

How Should You Choose a Liver Transplant Surgeon for Robotic Surgery?

1. A successful robotic liver surgery depends on creating a strong team both inside and outside the operating room.
2. The key components include a dedicated surgical team, anaesthesia team, and operating room staff.
3. The surgeon performing the surgery should be proficient at open hepatic surgery before attempting a minimally invasive technique.
4. Moreover, he/she should have a strong foundation in general laparoscopic and robotic surgery and should have undergone a formal training program to gain experience in robotic liver surgery. 

Following are the steps to complete a robotic liver surgery:

1. Incisions in the abdomen: The surgeon will mark the position for the robotic ports with a surgical pen. Generally, the ports should be placed in a horizontal line 15-20 cm from the liver. Each port should be placed 7-10 cm apart. Once the positions are marked, the surgeon will make small (one to two cm) incisions in your body. 
2. Insertion of robotic instruments: The surgeon then inserts mechanical arms with surgical instruments attached and a camera arm through the small incisions. The surgeon controls these arms while sitting at a computer console near the operating table. The computer console allows the surgeon to have a magnified, 3D view of the surgical site. 
3. Removal of the diseased liver: The surgeon then directs the robotic arms to carefully separate the damaged liver from the surrounding organs and structures. The attached veins and arteries will be secured to restrict the blood flow in the diseased liver. The robotic hands will then remove the diseased liver. 
4. Transplantation of the donor’s liver: The surgeon will control the robotic arms and attach the donor liver to your blood vessels. The blood flow to your new liver will be started, and the liver will be attached to the bile ducts. The surgeon will check for any bleeding via the computer images. 
5. Closure of the incisions: Once the new liver is attached, the surgeon will close the incisions with stitches or staples, and a drain may be placed into the incision site to reduce the swelling. Finally, the surgeon will apply a sterile bandage or dressing to the wound. 

Before the surgery

1. The doctor will advise a pre-anaesthetic checkup with an anaesthesiologist. 
2. You will undergo some diagnostic tests to ensure that you are healthy enough to receive the organ. 
3. He/she will enquire you about your medical history and appoint a date for the surgery.
4. If it’s a planned liver transplant, you will be asked to stop eating or drinking 8 hours before the surgery. If the liver is from a donor who just died, you should not eat or drink after being informed about the surgery. 
5. Your doctor will briefly explain the procedure, hospital stay, and insurance formalities. You can ask any questions you have regarding the surgery.

What Can You Expect on the Day of the Surgery?

1. The hospital staff will ask you to sign a consent form providing permission for the surgery. 
2. Someone from the team will ask you to change into a hospital gown and remove all jewellery pieces from your body. 
3. The nursing team will shave the surgical site. 
4. The doctor will record your last meal and give medicine to help you relax before the surgery. 
5. After your heart rate, blood pressure, breathing, and pulse are monitored, the team will shift you to the OT room. 

What Can You Expect During the Surgery?

1. The team will place you on your back on the operating table in the OT room. 
2. They will start an intravenous (IV) line for fluid and medicines in your arms. 
3. The anaesthesiologist will give you general anaesthesia. Once you are sedated, he/she will insert a tube in your lungs to help you breathe and monitor your vitals throughout the procedure. 
4. The team will clean the surgical site area with an antiseptic solution. 
5. The surgeon will make the necessary incisions, insert the robotic arms and other equipment, and control them to replace the diseased liver with a healthy donor liver. 
6. Finally, the surgical team will close the incision with stitches and apply a dressing to the wound. 

In Hospital

1. After the procedure, the team will move you to the recovery room, where they will monitor your vitals and the effect of anaesthesia.
2. Once your vitals stabilise, the team will escort you to the ICU. 
3. Your doctor will place a breathing tube in your throat for a few hours. 
4. IV drips will help your blood pressure, heart and control bleeding. 
5. The medical team will collect blood samples to check the new liver, kidneys, lungs, and circulatory system. 
6. Once your breathing and stomach tubes are removed, you may start drinking fluids and slowly begin to eat solid food. 
7. Depending on your condition, you may require to stay in the hospital overnight or for a couple of days. 
8. Before discharge, your doctor will provide you with home care and follow-up instructions. 

At Home

1. Your doctor will provide specific bathing instructions to keep the surgical area clean and dry.
2. You must eat a well-balanced diet to accelerate recovery and keep your liver healthy. 
3. After liver transplant surgery, physical activity and exercise should become a regular part of your life to improve your physical and mental health. 
4. You must avoid lifting heavy objects or engaging in strenuous activities for at least a month. 
5. Your provider will advise you to avoid driving for at least a week. 
6. The team will also help you join a support group for transplant recipients and find rehabilitation services. 

First Follow-Up Appointment

1. Your first follow-up appointment will typically be scheduled one or two weeks after the surgery.
2. Your doctor will remove your stitches during the visit and examine your recovery.
3. He/she will check if the liver is working properly and schedule further appointments for every two to four weeks. If needed, you may also visit a social worker or a psychiatric team member during your visit. 

Call your healthcare professional if you experience the following symptoms:

1. Fever (a sign of rejection by the body or infection)
2. Swelling or redness around the incision site
3. Bleeding or drainage from the incision site
4. Severe pain around the incision
5. Yellowing of skin and eyes
6. Vomiting or diarrhoea

Liver transplant surgery is the only treatment for liver failure in its last stage. If delayed or left untreated, the following complications can arise:

1. Cerebral oedema (excessive fluid in the brain)
2. Infections
3. Bleeding and bleeding disorders
4. Kidney failure