Robotic Liver Surgery for Colorectal Metastases

Liver resection is the standard treatment for colorectal liver metastases (CRLM). Metastases of colorectal origin, unlike other primary and metastatic liver diseases, have several features that distinguish them from other liver resections. First, most patients undergo neoadjuvant chemotherapy, which affects the quality of the liver because we almost always approach the liver with some degree of hepatocellular underlying diseases, whether steatosis, steatohepatitis, or sinusoidal obstruction syndrome (blue liver). Second, in many cases, the metastases are multiple and can affect both sides of the liver, which affects the resection strategy. Therefore, resection is often not standardized and the technique to be used can only be decided intraoperatively. The type of resection can vary and may include trisectionectomies, hemihepatectomies, segmentectomies, nonanatomic resections, and sometimes a combination of one or more techniques. Third, recurrence is a common event and repeat hepatectomy is very common. Therefore, many of the liver resections for metastases of colorectal origin are rehepatectomies. Therefore, many adhesions can be expected during the procedure. Even in the first hepatectomy, we can find adhesions from the resection of the primary colorectal tumor. Fourth, many of the metastases are synchronous, and in certain circumstances, resection of the primary tumor may be performed before, during, or after liver resection (liver first). Unlike hepatocellular carcinoma, portal vein thrombus is rare but can occur, and the robotic platform is extremely useful to treat this complication. For these reasons, the management of colorectal metastases has its own nuances that may affect the form and planning of surgical treatment. In this chapter, we discuss the various aspects of robotic liver surgery in patients with colorectal metastases.