Robotic versus Laparoscopic Liver Resection in Various Settings
Authors: Sijberden Jasper P. , Hoogteijling Tijs J. , Aghayan Davit , Ratti Francesca , Tan Ek-Khoon , Morrison-Jones Victoria , Lanari Jacopo , Haentjens Louis , Wei Kongyuan , Tzedakis Stylianos , Martinie John , Osei Bordom Daniel , Zimmitti Giuseppe , Crespo Kaitlyn , Magistri Paolo , Russolillo Nadia , Conci Simone , Görgec Burak , Benedetti Cacciaguerra Andrea , D’Souza Daniel , Zozaya Gabriel , Caula Cèlia , Geller David , Robles Campos Ricardo , Croner Roland , Rehman Shafiq , Jovine Elio , Efanov Mikhail , Alseidi Adnan , Memeo Riccardo , Dagher Ibrahim , Giuliante Felice , Sparrelid Ernesto , Ahmad Jawad , Gallagher Tom , Schmelzle Moritz , Swijnenburg Rutger-Jan , Fretland Åsmund Avdem , Cipriani Federica , Koh Ye-Xin , White Steven , Lopez Ben Santi , Rotellar Fernando , Serrano Pablo E. , Vivarelli Marco , Ruzzenente Andrea , Ferrero Alessandro , Di Benedetto Fabrizio , Besselink Marc G. , Sucandy Iswanto , Sutcliffe Robert P. , Vrochides Dionisios , Fuks David , Liu Rong , D’Hondt Mathieu , Cillo Umberto , Primrose John N. , Goh Brian K.P. , Aldrighetti Luca A. , Edwin Bjørn , Abu Hilal Mohammad ,   for the International consortium on Minimally Invasive Liver Surgery (I-MILS)
Published: March 2024

Objective:
The aim of this study was to compare the perioperative outcomes of robotic liver surgery (RLS) and laparoscopic liver surgery (LLS) in various settings.

Summary Background Data:
Clear advantages of RLS over LLS have rarely been demonstrated, and the associated costs of robotic surgery are generally higher than those of laparoscopic surgery. Therefore, the exact role of the robotic approach in minimally invasive liver surgery remains to be defined.

Methods:
In this international retrospective cohort study, the outcomes of patients who underwent RLS and LLS for all indications between 2009 and 2021 in 34 hepatobiliary referral centers were compared. Subgroup analyses were performed to compare both approaches across several types of procedures: minor resections in the anterolateral (2, 3, 4b, 5, and 6) or posterosuperior segments (1, 4a, 7, 8), and major resections (≥3 contiguous segments). Propensity score matching (PSM) was used to mitigate the influence of selection bias. The primary outcome was textbook outcome in liver surgery (TOLS), previously defined as the absence of intraoperative incidents ≥grade 2, postoperative bile leak ≥grade B, severe morbidity, readmission, and 90-day or in-hospital mortality with the presence of an R0 resection margin in case of malignancy. The absence of a prolonged length of stay was added to define TOLS+.

Results:
Among the 10.075 included patients, 1.507 underwent RLS and 8.568 LLS. After PSM, both groups constituted 1.505 patients. RLS was associated with higher rates of TOLS (78.3% vs. 71.8%, P<0.001) and TOLS+ (55% vs. 50.4%, P=0.026), less Pringle usage (39.1% vs. 47.1%, P<0.001), blood loss (100 vs. 200 milliliters, P<0.001), transfusions (4.9% vs. 7.9%, P=0.003), conversions (2.7% vs 8.8%, P<0.001), overall morbidity (19.3% vs. 25.7%, P<0.001) and R0 resection margins (89.8% vs. 86%, P=0.015), but longer operative times (190 vs. 210 min, P=0.015). In the subgroups, RLS tended to have higher TOLS rates, compared to LLS, for minor resections in the posterosuperior segments (n=431 per group, 75.9% vs. 71.2%, P=0.184) and major resections (n=321 per group, 72.9% vs. 67.5%, P=0.086), although these differences did not reach statistical significance.

Conclusions:
While both producing excellent outcomes, RLS might facilitate slightly higher TOLS rates than LLS.