Comments on Experience With Establishing a Robotic Donor Hepatectomy Program for Pediatric Liver Transplantation

Abstract

We have been asked to comment on the article by Rela et al,1 titled "Experience with Establishing a Robotic Donor Hepatectomy Program for Paediatric Liver Transplantation," published in this issue of Transplantation. In addition to reading the article with interest, we had the opportunity to visit the Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Center, Bharath Institute of Higher Education and Research, Chennai, India. There, we watched Dr Rela and his team perform a donor right hepatectomy and a donor left lateral segment hepatectomy using an entirely robotic approach. In this article, Professor Rela reports the thoughtful and graded approach to a robotic left lateral segmentectomy in 75 consecutive cases (September 2020 to July 2022), describing the technical aspects of the robotic approach, the background training of the lead surgeon, the technical steps in the operation, safeguards used, and the outcomes for the donors and recipients. An important safeguard placed at the outset was the mandatory conversion to an open procedure once 3 h had elapsed to ensure progression of the procedure. The subsequent 75 cases were all done completely with the robot, with a learning curve of approximately 16 cases to achieve time proficiency. The outcomes were excellent in both the donors and recipients. It is noteworthy that the assembled team has worked together for more than 10 y and consists of a lead surgeon at the console, another senior surgeon at the cavitron ultrasonic surgical aspirator (CUSA) port, 2 resident surgeons, 2 scrub nurses, and several circulators with various functions. There were many more individuals than we routinely see in our own operating rooms. We observed that the team worked seamlessly with each member well versed in their specific function. The CUSA activity is manned by a senior surgeon and must be done via a laparoscopic port as the DaVinci robot lacks a CUSA instrument. The senior CUSA surgeon is an important adjunct to operative technique and safety. The team is ready to revert to open procedure in the case of bleeding; 2 senior surgeons worked greatly to facilitate their action. It is noteworthy that we saw no second console in the operating theater in Chennai, which raises the question of how junior surgeons gain experience in this highly complex operative procedure based on a graded autonomy. The presence of a second console theoretically serves to provide increasing independence as well as an opportunity for the senior surgeon to assess and guide the junior individual.2–4 This theoretically serves to provide increasing independence as well as an opportunity for the senior surgeon to assess and guide the junior individual. The most interesting aspect of this article is the proposal by Dr Rela that a surgeon does not need to be proficient in laparoscopic skills to accomplish robotic surgery. And indeed, Dr Rela is a prime example of an individual who has mastered one of the most challenging surgeries done robotically without training or practice in laparoscopic techniques. The ergonomics of the robot and the magnification afforded by the machine have been recognized as advantages to the surgeon over laparoscopic approaches,5 but laparoscopic technique has been wider spread due to its earlier introduction and its relative cost saving when the cost of a robot is considered. Most US surgical trainees have achieved competence in laparoscopic work; it is relatively recent that graduating trainees are achieving robotic proficiency. Training in laparoscopic techniques is advantageous to learning robotic techniques in young trainees. The advantage to senior surgeons who are adapted at laparoscopic techniques is less clear,5,6 and there is a paucity of data in the acquisition of robotic skills in senior surgeons who are not laparoscopically trained. Dr Rela points out that open surgical experience is the key to successful robotic hepatectomy. A key question for us is whether t