BACKGROUND

Minimally invasive liver surgery (MILS) is superior to open surgery when considering decreased blood loss, fewer complications, shorter hospital stay, and similar or improved oncologic outcomes. However, operative limitations in laparoscopic hepatectomy have curved its applicability and momentum of complex minimally invasive liver surgery. Transitioning to robotic hepatectomy may bridge this complexity gap.

METHODS

Retrospective cohort study conducted on comparable hepatectomies (open, laparoscopic, robotic) for benign or malignant diseases at Weill Cornell by three surgeons from 2017 to 2023. Case volume and Iwate difficulty scoring were examined over time by surgical approach. Outcome associations (operative time, estimated blood loss, length of stay, 90-day complications, open conversion, and resection margin) were analyzed using generalized estimating equations to account for the hierarchical data structure of different surgeons and controlled for clinical covariates.

RESULTS

Among 353 hepatectomies, 112 were open (OH), 107 were laparoscopic (LH), and 134 were robotic (RH). OH patients were more likely to have malignant pathology (83% vs. LH 69%, RH 57%) and less likely to have cirrhosis (6% vs. LH 6%, RH 14%). OH and RH had similar case complexity (Median Iwate: OH 7 vs. RH 7). After adjustments, LH and RH had 39% and 43% shorter median lengths of stay, respectively, and 89% and 62% lower odds of complications compared to OH. RH had 87% lower odds of conversion to OH compared to LH. The odds of R0 resection were similar between LH, RH, and OH. These results remained consistent in high difficulty cases (Iwate 7-12). Over the study period, RH usage increased from 36 to 68%, while LH decreased from 39 to 9%. By 2023, RH was predominantly used over OH (74% vs.26%).

CONCLUSION

The transition from laparoscopic to all-robotic approach resulted in increased case volume and complexity in MILS, largely improving perioperative outcomes in hepatectomy.