Recently, reports of robotic hepatectomies have increased. In a laparoscopic hepatectomy, various energy devices are used for parenchymal transections, especially the clamp-crush method and the Cavitron Ultrasonic Surgical Aspirator (CUSA) system are popular; however, there is no CUSA that can be operated from the robot console. We believe that conventional clamp-crush method can be classified into four categories and have tried to verbalize them. We aim to explain the four types of clamp-crush techniques of robotic hepatectomy that we have performed and to assess their outcomes, safety, and feasibility. The data of patients who underwent robotic hepatectomy at Iwate Medical University Hospital between June 2022 and April 2024 were retrospectively reviewed. For comparison, 298 patients who underwent pure laparoscopic hepatectomy at Iwate Medical University Hospital between January 2014 and December 2020 were enrolled and analyzed. Our four clamp-crush techniques (Clamp, Peck, Open, Sweep) are demonstrated in the video clips provided with our study's electronic data. In the present study, 58 patients were included. In 27 cases (46.6%), a limited resection was performed; in 9 cases (15.5%), a subsegmentectomy; in 15 cases (25.9%), a sectionectomy; and in 7 cases (12.1%), a hemihepatectomy. The mean operative time was 205.9±90.5 min, and the mean intraoperative blood loss was 103.1±200.7 mL. There were no cases of conversion to a laparotomy. In comparison with laparoscopic hepatectomies, there were no significant differences in perioperative outcomes. The present findings indicate that robotic hepatectomies are safe and feasible in high-volume specialized centers with a team experienced in laparoscopic liver surgeries. It is possible to transition from laparoscopic hepatectomy to robotic hepatectomy without stress due to the fact that the same four clamp-crush techniques that are used in laparoscopic hepatectomy, which can be done in a robotic hepatectomy.

Robotic-assisted hepatectomy has gained traction in hepatobiliary surgery, but its cost-effectiveness compared to traditional surgical approaches remains unclear. This study investigates clinical outcomes and financial implications of robotic-assisted liver surgery in a high-volume center, comparing it with open and laparoscopic methods. A retrospective cohort study was conducted on patients undergoing hepatectomy at Lille University Hospital in 2018 and 2021, performed by the institution's first experienced robotic hepatobiliary surgeon. Data on patient demographics, intraoperative details, postoperative outcomes, and costs were analyzed. Costs included hospital stays, surgical materials, and complications, derived from national cost studies. A total of 111 patients were included, with a rise in minimally invasive procedures from 47.5% in 2018 to 75% in 2021. Robotic-assisted hepatectomy was associated with reduced hospital stays, lower complication rates, and fewer severe morbidities compared to laparotomy. The average cost per procedure (all surgical approaches combined) decreased from €12,169 in 2018 to €8,513 in 2021, with robotic surgery offering a significant financial advantage. The total savings for the 71 patients in the 2021 cohort was €259,576, driven primarily by reduced hospitalization times and fewer complications. Robotic-assisted hepatectomy is clinically safe and cost-effective, offering substantial financial savings over traditional surgery. The reduction in postoperative complications and hospital stay durations, particularly for complex cases, highlights the advantages of robotic surgery in hepatobiliary procedures. As surgical expertise increases, robotic surgery represents a sustainable and efficient alternative in liver resection.

In robotic surgery, surgical planning and surgical navigation represent two crucial elements, allowing surgeons to maximize surgical outcomes while minimizing the risk of complications. In this context, an emerging imaging technology, namely augmented reality (AR), can represent a powerful tool to create an integration of preoperative 3D models into the live intraoperative view, providing an interactive visual interface rather than a simple operative field. In this way, surgeons can be guided by preoperative imaging during the operation. This makes the surgical procedure more accurate and safer, leading to so-called "precision surgery". This article aims to provide an overview of developments in the application of AR in robotic general surgery. The integration of this imaging technology in this surgical field is showing promising results. The main benefits include improved oncological outcomes and reduced occurrence of complications. In addition, its application may also be important for surgical education. However, we are still in the initial phase of the experience and some important limitations remain. Moreover, to our knowledge, to date, reports in the literature regarding the integration of AR in robotic general surgery are still very limited. To improve its application, close collaboration between engineers, software developers, and surgeons is mandatory.

Robotic surgery is becoming more and more widespread. Despite its diffusion, parenchymal transection still remains a matter of debate. Up to now, in minimally invasive surgery, most of liver resection were performed laparoscopically with the support of ultrasonic dissector. The absence of robotic ultrasonic dissector is replaced by the hybrid (Robo-lap) technique in which the use of laparoscopic ultrasonic dissector is merged with the use of robotic energy devices in order to perform parenchymotomy. On the other side, some surgical groups perform liver resection using only Da Vinci energy devices, focusing on the simultaneous use of the double bipolar forceps (Maryland and bipolar) and applying the clamp-crush technique during robotic resection (MAMBA-Moisture Assisted Multiple BipolAr). Aim of our study is to compare intra- and post-operative outcomes of these two techniques.

We collected a multicenter retrospective database, including 1070 consecutive robotic liver resection in 10 European Hospital Centers. Among these, 921 patients underwent liver resection for malignancies. Perioperative data for each patient were analyzed. Patients were also divided in two groups according to parenchymal transection technique (MAMBA vs robo-lap). Perioperative data were compared between 2 groups before and after 1:1 Propensity Score Matching.

755 resection were performed by MAMBA technique, 166 resection by Robo-lap. After PSM, 91 patients were included in each group. There were no significant differences between two groups regarding operative time, estimated blood loss, conversion rate, and post-operative complications.

MAMBA technique is a valid alternative in robotic liver parenchymal transection, overcoming the lack of ultrasound devices.

Minimal access liver surgery (MALS) is considered superior to open liver resection (OLR) in reducing the perioperative risk in patients affected by hepatocellular carcinoma (HCC). No national-level comparisons exist based on procedure complexity. This study aims to compare postoperative complications, postoperative ascites (POA), and major complications (MC) between MALS and OLR.

Data were retrieved from the Italian HE. RC.O.LE.S. registry. Patients were categorized into OLR or MALS groups and stratified by complexity grade (CP1, CP2, CP3). An inverse probability weighting (IPW) was performed to ensure balanced comparisons.

From 2008 to 2021, 4738 patients were included: 1596 (33.7 %) underwent MALS, and 3142 (66.3 %) underwent OLR. CP1 procedures were conducted in 2522 cases (53.2 %), CP2 in 974 cases (20.5 %), and CP3 in 1242 cases (26.2 %). For CP1, MALS was associated with reduced POA (OR 0.356, 95%CI:0.29-0.43, p < 0.001), and MC (OR 0.738, 95%CI:0.59-0.91, p: 0.006). In CP2, MALS showed association with MC (OR 0.557, 95%CI:0.37-0.82, p:0.004), but not with POA. For CP3, MALS was associated with increased MC risk (OR 1.441, 95%CI:1.10-1.88, p:0.008). Low-volume centers had significantly higher MC risks after CP2 and CP3 procedures than medium or high-volume centers.

In CP1 and CP2 procedures, MALS was proven advantageous in reducing POA and MC. Among CP3, MALS increased the risk of MC, but not among high-volume centres.

Currently, no practical definition of potentially resectable, borderline or unresectable perihilar cholangiocarcinoma (pCCA) is available. Aim of this study was to define criteria to categorize patients for use in a future neoadjuvant or induction therapy study.

Using the modified DELPHI method, hepatobiliary surgeons from all tertiary referral centers in the Netherlands were invited to participate in this study. During five online meetings, predefined factors determining resectability and additional factors regarding surgical resectability and operability were discussed.

The five online meetings resulted in 52 statements. After two surveys, consensus was reached in 63% of the questions. The main consensus included a definition regarding potential resectability. 1) Clearly resectable: no vascular involvement (≤90°) of the future liver remnant (FLR) and expected feasibility of radical biliary resection. 2) Clearly unresectable: non-reconstructable venous and/or arterial involvement of the FLR or no feasible radical biliary resection. 3) Borderline resectable: all patients between clearly resectable and clearly unresectable disease.

This DELPHI study resulted in a practical and applicable resectability, or more accurate, an explorability classification, which can be used to categorize patients for use in future neoadjuvant therapy studies.

To compare the efficacy and safety of robot-assisted laparoscopic hepatectomy (RALH) with laparoscopic hepatectomy (LH) in the treatment of liver tumors.

A comprehensive search of English-language literature was conducted in PubMed, Embase, Web of Science, and the Cochrane Library from January 2000 to June 2024. Studies comparing RALH and LH for liver tumors were identified, and after qualitative evaluation, a meta-analysis was performed using Stata 16.0 software.

After applying inclusion and exclusion criteria, 42 articles were included, including 29,969 patients, with 5673 in the RALH group and 24,296 in the LH group. The meta-analysis showed that compared with the LH group, surgery time was longer in the RALH group (MD = 55.33; 95% CI: 34.84-75.83; P < .001), the conversion to open surgery rate was higher (RR = 1.04; 95% CI: 1.03-1.05; P < .001), the total cost was higher (MD = 0.43; 95% CI: 0.14-0.73; P = .004), and the tumor diameter was larger (MD = 0.37; 95% CI: 0.24-0.49; P < .001). Additionally, the R1 resection rate was higher in the RALH group (RR = 1.04; 95% CI: 1.03-1.06; P < .001). However, there were no significant differences between the groups in terms of intraoperative transfusion rate, hepatic hilar occlusion rate, postoperative complications, postoperative hospital stay, mortality rate, malignancy rate, or R0 resection rate (P > .05).

Based on current evidence, RALH is safe and effective, although it is associated with higher total costs, increased blood transfusion rates, and longer operative times. However, there were no significant differences between RALH and LH in terms of other outcome indicators, suggesting that both procedures offer similar surgical efficacy and safety. Further clinical randomized controlled trials are needed to confirm these findings.

Limited and heterogeneous literature data necessitate a focused examination of the learning curve in robotic liver resections. This study aims to assess the learning curve of two surgeons from the same team with differing laparoscopic backgrounds.

Since February 2021, San Raffaele Hospital in Milan has implemented a robotic liver surgery program, performing 250 resections by three trained console surgeons. Using cumulative sum (CUSUM) analysis, the learning curve was evaluated for a Pioneer Surgeon (PS) with around 1200 laparoscopic cases and a New Generation Surgeon (NGS) with approximately 100 laparoscopic cases. Cases were stratified by complexity (38 low, 74 intermediate, 85 high).

Both PS and NGS demonstrated a learning curve for operative time after 15 low-complexity and 10 intermediate-complexity cases, with high-complexity learning curves apparent after 10 cases for PS and 18 cases for NGS. Conversion rates remained unaffected, and neither surgeon experienced increased blood loss or postoperative complications. A "team learning curve" effect in terms of operative time emerged after 12 cases, suggesting the importance of a cohesive surgical team.

The robotic platform facilitated a relatively brief learning curve for low and intermediate complexity cases, irrespective of laparoscopic background, underscoring the benefits of team collaboration.

Minimally invasive liver surgery has become widely accepted as a safe and effective approach, especially with experienced surgeons. Robotic hepatectomy may offer significant benefits in challenging procedures like caudate lobe resection. The caudate lobe's intricate anatomy and deep-seated location make its resection particularly challenging, with limited reports on minimally invasive techniques. The aim of this study was to assess the feasibility and safety of robotic isolated complete caudectomy and to provide a detailed description of the different technical approaches available. This retrospective multicenter study was conducted across eight experienced hepatobiliary robotic surgery centers between June 2020 and March 2024. All patients who underwent elective RICC during this period were included. Data were prospectively collected and retrospectively analyzed, focusing on demographics, intraoperative variables, postoperative outcomes, and histopathological results. The primary outcome was the feasibility and safety of the robotic approach. The study included 42 patients. The median (IQR) operative time was 180 (125-245) min, with a median estimated blood loss of 30 (0-100) ml. There were no conversions to open surgery and only one severe complication (Clavien-Dindo ≥ 3) occurred. No postoperative mortality was observed, and all resections for malignant lesions achieved R0 margins. The median time to flatus was 1 (1-1) day, time to solid diet was 1 (1-2) days, and the median length of stay was 3 (2-4) days. RICC is a feasible and safe procedure, demonstrating significant benefits in operative efficiency and patient recovery. However, further research with larger, prospective multicenter studies is necessary to confirm these findings and assess long-term outcomes.

Minimally invasive distal pancreatectomy offers recognised benefits over open surgery. Robotic surgery, with its shorter learning curve and technical advancements, presents a promising alternative to laparoscopy in managing pancreatic diseases.

This study enrolled consecutive patients undergoing distal pancreatectomy between January 2013 and May 2022. After propensity score matching, perioperative and medium-term outcomes were compared between robotic and open procedures.

Among 79 patients analysed, 50 were eligible after matching. Both groups showed similar demographics, with 11% experiencing grade III-IV complications, and one patient died within 90 days after surgery. Robotic surgery exhibited longer operating times but allowed for earlier refeeding, drain removal, canalisation, and shorter hospital stays compared with open surgery. Spleen preservation rates, postoperative pancreatic fistula occurrences and survival were comparable between the groups.

Overall, robotic and open distal pancreatectomy demonstrated similar outcomes, with robotic surgery offering advantages in certain postoperative parameters despite longer operation times.

Central liver segments resection (CLSR) still is not widely used in pediatric surgery due to its technical difficulty, whereas this procedure is widely spread as a parenchyma sparing approach of centrally located liver tumors in adults. The aim of this study is to analyze the outcomes of CLSR in comparison with extended hepatectomy (EH) in children with different liver tumors.

A single-center retrospective analysis of patients who received CLSR (n = 14) and EH (n = 44) from June 2017 to December 2023 was applied. Patient's characteristics, preoperative, intra- and postoperative data were compared between 2 groups.

Preoperative CT-volumetry showed that future liver remnant volume was higher in CLSR group compared to EH (FLR-V; (54 ± 29 (40-91) % vs 40 ± 12 (17-73) %, p = 0.016). The intraoperative blood loss (200 [90-1150] (20-3000) ml vs 100 [30-275] (10-9000) ml, p = 0.088) and transfusion volume (310 [85-590] (0-1860) ml vs 150 [0-310] (0-4770) ml, p = 0.484) were similar in both groups, while operation time was longer in CLSR group (420 [320-595] (145-785) min vs 280 [203-390] (125-710) min), p = 0.011). There was no difference in biliary leakage (3 (21.4 %) vs 12 (27.3 %); p = 0.479), other complications (4 (28.6 %) vs 5 (11.4 %), p = 0.198) and complications ≥ IIIb by Clavien-Dindo (2 (14.3 %) vs 8 (18.2 %), p = 0.385) postoperatively.

CLSRs allow to preserve more healthy liver parenchyma compared to EH with similar intraoperative and postoperative outcomes. «Extended mesohepatectomy» allows to achieve R0 resection when central liver tumor extends on the left lateral and/or right posterior section.

Retrospective Comparative Study (Level of Evidence III).

The adoption of robotic techniques in liver surgery introduces significant challenges for their safe integration within hepatobiliary surgery units. This study is designed to investigate the complexities associated with establishing a robotic surgery program.

Data on robotic hepatobiliary surgeries were prospectively collected from October 2021 to October 2023. Historical cohorts from the institutional experiences for comparison were hand-assisted (HALS) and purely laparoscopic procedures (PLS). Inverse probability of treatment weighting and propensity score matching were employed to compare outcomes between PLS and robotic resections. The learning curve for robotic surgeries was evaluated by the cumulative sum method.

In this study, 454 patients were enrolled (113 robotic surgeries, 157 HALS, and 184 PLS). The posterosuperior segments resections were significantly higher in the robotic group (47.8%) compared to PLS (31.5%) and HALS (35.7%). There were no conversions in the robotic group, in PLS 2.7% and HALS 3.8%. The degree of difficulty according to the median of the IWATE score and IMM score was significantly higher in the robot group (p < 0.001 and p = 0.008, respectively). No significant differences in short-term outcomes were observed between robotic procedures and PLS in a matched subset of patients. Operative efficiency and blood loss improved significantly after the 75th robotic surgery patient, with high-difficulty cases (IWATE ≥ 10) incorporated from the beginning.

This study suggests that robotic liver surgery in units with prior experience in minimally invasive liver surgery offers benefits, such as a lower conversion rate and a higher rate of successful difficult resections.

As in many surgical branches, minimally invasive methods are becoming increasingly prominent in hepatobiliary surgery. Nowadays, robotic and laparoscopic methods are among the hot topics in the current literature. Both laparoscopic and robotic surgery have better short-term results than open surgery in terms of the blood loss, need for blood transfusion, length of intensive care unit and hospital stay, and postoperative major complication rate. In addition to cosmetic benefits, minimally invasive methods have similar results to open surgery in terms of oncologic outcomes. Minimally invasive techniques for hepatocellular carcinoma, colorectal cancer liver metastasis and cholangiocarcinoma, which are the most common indications for surgery, also for donor and recipient surgeries in organ transplantation, can be safely applied in high-volume centers and by experienced surgeons. The use of robotic surgery is increasing especially in major hepatectomy operations. The main advantages of robotic surgery over laparoscopic surgery are less bleeding, less conversion rate and a shorter learning curve. However, there is a need for studies investigating the cost-effectiveness of robotic surgery, the production of devices such as robotic ultrasonographic dissectors, and the establishment of structured minimally invasive hepatobiliary surgery training programs. The aim of this review is to evaluate the recent findings and current evidence on minimally invasive hepatobiliary surgery.

This study's aim was to show the feasibility and safety of robotic liver resection (RLR) even without extensive experience in major laparoscopic liver resection (LLR).

A single center, retrospective analysis was performed for consecutive liver resections for solid liver tumors from 2014 to 2022.

The analysis included 226 liver resections, comprising 127 (56.2%) open surgeries, 28 (12.4%) LLR, and 71 (31.4%) RLR. The rate of RLR increased and that of LLR decreased over time. In a comparison between propensity score matching-selected open liver resection and RLR (41:41), RLR had significantly less blood loss (384 ± 413 vs 649 ± 646 mL, P = .030) and shorter hospital stay (4.4 ± 3.0 vs 6.4 ± 3.7 days, P = .010), as well as comparable operative time (289 ± 123 vs 290 ± 132 mins, P = .954). A comparison between LLR and RLR showed comparable perioperative outcomes, even with more surgeries with higher difficulty score included in RLR (5.2 ± 2.7 vs 4.3 ± 2.5, P = .147). The analysis of the learning curve in RLR demonstrated that blood loss, conversion rate, and complication rate consistently improved over time, with the case number required to achieve the learning curve appearing to be 60 cases.

The findings suggest that RLR is a feasible, safe, and acceptable platform for liver resection, and that the safe implementation and dissemination of RLR can be achieved without solid experience of LLR.

Worldwide use of robotic-assisted hepatectomy has increased dramatically over the past two decades. The role of robotic liver surgery is still controversial, especially with respect to its long-term oncological outcomes in treating early-stage hepatocellular carcinoma (HCC). The Glissonean approach is a fundamental technique for anatomical resection using open and laparoscopic liver surgery. To our knowledge, there have been few reports on purely robotic anatomical segmentectomy 7 for HCC using the Glissonean approach have been described. The present study describes the technical details and surgical outcomes of totally robotic segmentectomy 7 using the Glissonean approach. Fourteen patients with HCC limited to segment 7 underwent segmentectomy 7 from January 2019 through April 2023 in our hospital. The surgical techniques, peri-operative, and oncological outcomes were analyzed. Purely robotic anatomical segmentectomy 7 using the Glissonean approach was safe and feasible with the technology described herein in all of the 14 patients. The peri-operative and oncological outcomes were better and/or comparable with those of other similar hepatic resections using open approach and/or laparoscopic approach. The median follow-up time was 18 months. Intrahepatic recurrence occurred in 2 (14.3%) patient within one year following surgery. The 3-year overall survival rate was 81%. Although technically challenging, the purely robotic segmentectomy 7 could be performed safely and simultaneously with oncological radicality using the Glissonean approach.

Introduction Anatomical hepatectomy for segment 7 (S7) lesions is technically challenging due to their restricted accessibility and close proximity to the right hepatic vein, and the robotic approach for this challenging situation is currently not supported by conclusive data. Methods We present our novel technique of robotic anatomical hepatectomy for S7 lesions utilizing the saline-linked cautery (SLiC) method. Between 2022 and 2023, 10 robotic S7 subsectionectomy or right posterior sectionectomy were performed and included in the current study. The historical control group included patients undergoing laparoscopic anatomical hepatectomy for S7 lesions between 2017 and 2021 (n=9). Surgical outcomes were compared between the groups to assess the efficacy and safety of our technical robotic approach for S7 lesions. Results There were no conversions to open liver resection, no cases of grade B or C post-hepatectomy liver failure, and no mortality in the whole cohort. Although no difference was found between the laparoscopic and robotic groups in the difficulty score, operative time, and rate of red blood cell transfusion, the robotic group had a significantly lesser amount of surgical blood loss (28mL vs. 280mL, p=0.005). Concerning postoperative complications, one patient had liver subcapsular hematoma in the robotic group, although neither bile leakage nor intraperitoneal abscess occurred in the whole cohort. Conclusions Although robotic right posterior sectionectomy and S7 subsectionectomy of the liver are technically demanding procedures, the intrahepatic Glissonean approach using the SLiC method is safe and feasible. It might be performed without increasing the incidence of postoperative complications. Thus, the current approach can be considered as one of the preferred options for robotic anatomical hepatectomy for S7 lesions.

Robotic liver resection (RLR) faces challenges in parenchymal dissection due to device limitations, necessitating the development of a safe, efficient, and versatile method for its widespread use. We introduce our six-port RLR approach utilizing the double bipolar clamp-crush method with saline drops to overcome these device limitations. This method, combined with robotic bipolar forceps, maximizes the advantages of RLR by leveraging its multi-joint functionality and facilitates the dissection of strong, fibrotic liver tissue through the use of bipolar energy. The assistant surgeon strategically drops saline solution from an electrocautery system onto the operative field, while simultaneously removing crushed tissue, blood, and excess moisture using an endoscopic suction system through two assistant trocars. This process prevents tissue adhesion to the forceps and carbonization while maintaining a moist environment. Hemostasis is achieved using bipolar or monopolar coagulation under these conditions, with multiple hemostatic devices ensuring safety. In our study, RLR was performed on 16 lesions in 13 patients, including two with cirrhosis and portal hypertension. Median blood loss was 27 mL, and no postoperative complications occurred. The forceps were changed a median of four times due to tissue adherence during liver parenchymal dissection, which prevented tissue adhesion and facilitated efficient hepatic resection. Although further advances in instrumentation technology for RLR are needed, we are confident that our method will lower the barriers for many surgeons to adopt robotic liver resection and contribute to its further widespread use. Our six-port double bipolar clamp-crush method with saline drops shows promise for safe, efficient, and versatile liver parenchymal resection in current RLR practice.

Despite a growing body of literature supporting the safety of robotic hepatopancreatobiliary (HPB) procedures, the adoption of minimally invasive techniques in HPB surgery has been slow compared to other specialties. We aimed to identify barriers to implementing robotic assisted surgery (RAS) in HPB and present a framework that highlights opportunities to improve adoption.

A modified nominal group technique guided by a 13-question framework was utilized. The meeting session was guided by senior authors, and field notes were also collected. Results were reviewed and free text responses were analyzed for major themes. A follow-up priority setting survey was distributed to all participants based on meeting results.

Twenty three surgeons with varying robotic HPB experience from different practice settings participated in the discussion. The majority of surgeons identified operating room efficiency, having a dedicated operating room team, and the overall hospital culture and openness to innovation as important facilitators of implementing a RAS program. In contrast, cost, capacity building, disparities/risk of regionalization, lack of evidence, and time/effort were identified as the most significant barriers. When asked to prioritize the most important issues to be addressed, participants noted access and availability of the robot as the most important issue, followed by institutional support, cost, quality of supporting evidence, and need for robotic training.

This study reports surgeons' perceptions of major barriers to equitable access and increased implementation of robotic HPB surgery. To overcome such barriers, defining key resources, adopting innovative solutions, and developing better methods of collecting long term data should be the top priorities.

We have previously reported a saline-linked bipolar clamp-crush technique as a novel robotic liver resection method. Herein, we present the surgical techniques and outcomes of robotic left hepatectomy using the Glissonean approach and our liver transection technique.

The key procedures included the following: (1) encircling the left Glissonean pedicle using the Tip-Up fenestrated grasper, (2) dissecting the liver parenchyma using the saline-linked bipolar clamp-crush technique, (3) moving the endoscope one trocar to the right to facilitate visualisation of the liver transection plane, and (4) stapling the left pedicle and left hepatic vein. Seven robotic left hepatectomies were performed.

The median operative time and estimated blood loss were 395 min and 50 mL, respectively. The median length of postoperative hospital stay was 9 days. Pneumothorax was the only severe postoperative complication.

Robotics left hepatectomy using the Glissonean approach and the saline-linked bipolar clamp-crush technique appears safe and feasible.

Robotic liver resection has been reported in case series since the early 2000s. The surgical robot is capable of precise operation using articulated forceps with seven degrees of freedom. The robot also eliminates tremors and provides a good surgical field with highly detailed 3D high-definition images. The clinical results demonstrating their usefulness have been increasing year by year. Initially, a shorter hospital stay was observed in comparison with open hepatectomy. Recent reports have also shown lower conversion and complication rates in comparison with laparoscopic hepatectomy. The clamp and crush method with bipolar forceps, sealing devices, ultrasonic shears, and the combined procedure of Cavitron ultrasonic surgical aspirator and robotic forceps as hybrid procedures have been reported as effective methods of parenchymal transection in robotic surgery. Theoretically, the advantages of the robotic platform allow for more complex liver resection around hilar structures and major blood vessels, as well as for vascular reconstruction or biliary reconstruction. The application of robotic liver surgery for hilar cholangiocarcinoma, living donor hepatectomy, and living donor liver transplantation has been reported. Robotic liver surgery is becoming more popular for certain indications; however, it is important to further evaluate its long-term surgical and oncological outcomes and costs in comparison with conventional laparoscopic and open liver surgery, based on accumulated experience.

The liver requires careful handling intra-operatively owing to its vital functions and complexity. Traditional open hepatectomy, while standard, is invasive and requires long recovery periods. Laparoscopic hepatectomy is a less invasive option, with its own challenges. The rise of robotic surgery, such as the da Vinci® system, improves precision and control, addressing the limitations of conventional methods, but brings new concerns, such as costs and training. This review focuses on the latest advancements in robotic hepatectomy from 2022/23 articles, delving into topics like "robotic surgery in liver transplantation," "robotic hepatectomy for hilar cholangiocarcinoma," "robotic vascular reconstruction following hepatectomy," "robotic repeat hepatectomy," and "prospective trials in robotic hepatectomy." To retrieve articles, a focused literature search was conducted using PubMed for articles from 2022/23 with a 5-year filter, excluding reviews. Initially, abstracts were screened, and relevant articles on robotic surgery were examined in full for inclusion in this review. Although all the above items are cutting-edge, and many of the references are necessarily at the level of case reports, recent articles are still accompanied by surgical videos, which are useful to readers, especially surgeons who are considering imitating the procedures. In summary, we examined the recent advancements in robotic liver resection. The inclusion of videos that present new techniques aids in knowledge transfer. We anticipate the continued growth of this field of research.

The safety and efficacy of robotic liver resection (RLR) for patients with hepatocellular carcinoma (HCC) have been reported worldwide. However, the exact role of RLR in HCC patients with liver cirrhosis is not sufficiently determined.

We conducted a retrospective study on consecutive patients with cirrhosis or non-cirrhosis who received RLR for HCC from 2018 to 2023. Data on patients' demographics and perioperative outcomes were collected and analyzed. Propensity score matching (PSM) analysis was performed. Multivariate logistic regression analysis was performed to determine the risk factors of prolonged postoperative length of stay (LOS) and morbidity.

Of the 571 patients included, 364 (64%) had cirrhosis. Among the cirrhotic patients, 48 (13%) were classified as Child-Pugh B. After PSM, the cirrhosis and non-cirrhosis group (n = 183) had similar operative time, estimated blood loss, postoperative blood transfusion, LOS, overall morbidity (p > 0.05). In addition, the intraoperative and postoperative outcomes were similar between the two groups in the subgroup analyses of patients with tumor size ≥ 5 cm, major hepatectomy, and high/expert IWATE difficulty grade. However, patients with Child-Pugh B cirrhosis had longer LOS and more overall morbidity than that of Child-Pugh A. Child-Pugh B cirrhosis, ASA score > 2, longer operative time, and multiple tumors were risk factors of prolonged LOS or morbidity in patients with cirrhosis.

The presence of Child-Pugh A cirrhosis didn't significantly influence the difficulty and perioperative outcomes of RLR for selected patients with HCC. However, even in high-volume center, Child-Pugh B cirrhosis was a risk factor for poor postoperative outcomes.

Evidence concerning long-term outcome of robotic liver resection (RLR) and laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) patients is scarce.

This study enrolled all patients who underwent RLR and LLR for resectable HCC between July 2016 and July 2021. Propensity score matching (PSM) was employed to create a 1:3 match between the RLR and LLR groups. A comprehensive collection and analysis of patient data regarding efficacy and safety have been conducted, along with the evaluation of the learning curve for RLR.

Following PSM, a total of 341 patients were included, with 97 in the RLR group and 244 in the LLR group. RLR group demonstrated a significantly longer operative time (median [IQR], 210 [152.0-298.0] min vs. 183.5 [132.3-263.5] min; p = 0.04), with no significant differences in other perioperative and short-term postoperative outcomes. Overall survival (OS) was similar between the two groups (p = 0.43), but RLR group exhibited improved recurrence-free survival (RFS) (median of 65 months vs. 56 months, p = 0.006). The estimated 5-year OS for RLR and LLR were 74.8% (95% CI: 65.4-85.6%) and 80.7% (95% CI: 74.0-88.1%), respectively. The estimated 5-year RFS for RLR and LLR were 58.6% (95% CI: 48.6-70.6%) and 38.3% (95% CI: 26.4-55.9%), respectively. In the multivariate Cox regression analysis, RLR (HR: 0.586, 95% CI (0.393-0.874), p = 0.008) emerged as an independent predictor of reducing recurrence rates and enhanced RFS. The operative learning curve indicates that approximately after the 11th case, the learning curve of RLR stabilized and entered a proficient phase.

OS was comparable between RLR and LLR, and while RFS was improved in the RLR group. RLR demonstrates oncological effectiveness and safety for resectable HCC.

Although minimally invasive hepato-pancreato-biliary (MIS HPB) surgery can be performed with good outcomes, there are currently no standardized requirements for centers or surgeons who wish to implement MIS HPB surgery. The aim of this study was to create a consensus statement regarding safe dissemination and implementation of MIS HPB surgical programs.

Sixteen key questions regarding safety in MIS HPB surgery were generated after a focused literature search and iterative review by three field experts. Participants for the working group were then selected using sequential purposive sampling and snowball techniques. Review of the 16 questions took place over a single 2-h meeting. The senior author facilitated the session, and a modified nominal group technique was used.

Twenty three surgeons were in attendance. All participants agreed or strongly agreed that formal guidelines should exist for both institutions and individual surgeons interested in implementing MIS HPB surgery and that routine monitoring and reporting of institutional and surgeon technical outcomes should be performed. Regarding volume cutoffs, most participants (91%) agreed or strongly agreed that a minimum annual institutional volume cutoff for complex MIS HPB surgery, such as major hepatectomy or pancreaticoduodenectomy, should exist. A smaller proportion (74%) agreed or strongly agreed that a minimum annual surgeon volume requirement should exist. The majority of participants agreed or strongly agreed that surgeons were responsible for defining (100%) and enforcing (78%) guidelines to ensure the overall safety of MIS HPB programs. Finally, formal MIS HPB training, minimum case volume requirements, institutional support and infrastructure, and mandatory collection of outcomes data were all recognized as important aspects of safe implementation of MIS HPB surgery.

Safe implementation of MIS HPB surgery requires a thoughtful process that incorporates structured training, sufficient volume and expertise, a proper institutional ecosystem, and monitoring of outcomes.

Surgery plays a key role in the multi-disciplinary cancer care pathway. Nearly 80% of patients with solid tumors will require surgical intervention during the course of their disease. Unfortunately, the vast majority of these patients do not have access to safe, timely, high-quality, and affordable cancer surgical care. The first Lancet Oncology Commission on Global Cancer Surgery shone a light on this grave situation and outlined some strategies to address them. The second Lancet Oncology Commission on Global Cancer Surgery (TLO- II) was conceived to continue the work of its predecessor by developing a roadmap of practical solutions to propel improvements in cancer surgical care globally.

The Commission was developed by involving approximately 50 cancer care leaders and experts from different parts of the world to ensure diversity of input and global applicability.

The Commission identified nine solutional domains that are considered essential to deliver safe, timely, high-quality, and affordable cancer surgical care. These nine domains were further refined to develop solutions specific to each of the six World Health Organization regions. Based on the above solutions, we developed eight action items that are intended to propel improvements in cancer surgical care on the global stage.

The second Lancet Oncology Commission on Global Cancer Surgery builds on the first Commission by developing a pragmatic roadmap of practical solutions that we hope will ensure access to safe, timely, high-quality, and affordable cancer surgical care for everyone regardless of their socioeconomic status or geographic location.

This study comprehensively compared laparoscopic liver resection (LLR) to open liver resection (OLR) in treating colorectal cancer liver metastasis (CRLM).

A systematic review of relevant literature was conducted to assess a range of crucial surgical and oncological outcomes.

Findings indicate that minimally invasive surgery (MIS) did not significantly prolong the duration of surgery compared to open liver resection and notably demonstrated lower blood transfusion rates and reduced intraoperative blood loss. While some studies favored MIS for its lower complication rates, others did not establish a statistically significant difference. One study identified a lower post-operative mortality rate in the MIS group. Furthermore, MIS consistently correlated with shorter hospital stays, indicative of expedited post-operative recovery. Concerning oncological outcomes, while certain meta-analyses reported a lower rate of cancer recurrence in the MIS group, others found no significant disparity. Overall survival and disease-free survival remained comparable between the MIS and open liver resection groups.

The analysis emphasizes the potential advantages of LLR in terms of surgical outcomes and aligns with existing literature findings in this field.

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the role of minimally invasive liver surgery has been progressively developed, with the practice increasing in safety and feasibility also with respect to major liver resections. The aim of this study was to analyze the feasibility and safety of major liver resection in elderly patients.

data from a multicentric retrospective database including 1070 consecutive robotic liver resections in nine European hospital centers were analyzed. Among these, 131 were major liver resections. Patients were also divided in two groups (<65 years old and ≥65 years old) and perioperative data were compared between the two groups.

a total of 131 patients were included in the study. Operative time was 332 ± 125 min. Postoperative overall complications occurred in 27.1% of patients. Severe complications (Clavien Dindo ≥ 3) were 9.9%. Hospital stay was 6.6 ± 5.3 days. Patients were divided into two groups based on their age: 75 patients < 65 years old and 56 patients ≥ 65 years old. Prolonged pain, lung infection, intensive care stay, and 90-day readmission were worse in the elderly group. The two groups were matched for ASA and Charlson comorbidity score and, after statistical adjustment, postoperative data were similar between two groups.

robotic major liver resection in elderly patients was associated with satisfying short-term outcomes.

Background/Objectives: The IWATE criteria are well-established as a helpful tool to preoperatively estimate the difficulty and perioperative outcome of laparoscopic liver resections. We evaluated the relationship between the IWATE criteria and the perioperative outcomes in robotic-assisted liver resections (RARLs). Methods: We retrospectively analyzed the data of 58 patients who underwent robotic-assisted liver surgery at our center between July 2019 and April 2023. The operative difficulty of every patient was graded according to the IWATE criteria and compared to the perioperative outcome. Results: The median operation time was 236.5 min (range 37-671 min), and the median length of stay was 6 days (range 3-37 min). The majority had no complications (65.5%; n = 38), 18 (31.0%) patients suffered from mild complications (CD ≤ 3A) and 2 patients (3.4%) suffered from relevant complications (CD ≥ 3B). We observed no deaths within 30 postoperative days. The surgery time, postoperative ICU stay and perioperative blood transfusions increased significantly with a higher difficulty level (p = < 0.001; p < 0.001; p = 0.016). The length of stay, conversion to open surgery (n = 2) and complication rate were not significantly linked to the resulting IWATE group. Conclusions: The IWATE criteria can be implemented in robotic-assisted liver surgery and can be helpful in preoperatively estimating the difficulty of robotic liver resections. Whether there is a "robotic effect" in minimally invasive liver resections has to be further clarified. The IWATE criteria can help to develop curricula for robotic training.

Due to the success of minimally invasive liver surgery, laparoscopic and robotic minimally invasive donor hepatectomies (MIDH) are increasingly performed worldwide. We conducted a retrospective, multicentre, propensity score-matched analysis on right lobe MIDH by comparing the robotic, laparoscopic, and open approaches to assess the feasibility, safety, and early outcomes of MIDHs. From January 2016 until December 2020, 1194 donors underwent a right donor hepatectomy performed with a robotic (n = 92), laparoscopic (n = 306), and open approach (n = 796) at 6 high-volume centers. Donor and recipients were matched for different variables using propensity score matching (1:1:2). Donor outcomes were recorded, and postoperative pain was measured through a visual analog scale. Recipients' outcomes were also analyzed. Ninety-two donors undergoing robotic surgery were matched and compared to 92 and 184 donors undergoing laparoscopic and open surgery, respectively. Conversions to open surgery occurred during 1 (1.1%) robotic and 2 (2.2%) laparoscopic procedures. Robotic procedures had a longer operative time (493 ± 96 min) compared to laparoscopic and open procedures (347 ± 120 and 358 ± 95 min; p < 0.001) but were associated with reduced donor blood losses ( p < 0.001). No differences were observed in overall and major complications (≥ IIIa). Robotic hepatectomy donors had significantly less pain compared to the 2 other groups ( p < 0.001). Fifty recipients of robotic-procured grafts were matched to 50 and 100 recipients of laparoscopic and open surgery procured grafts, respectively. No differences were observed in terms of postoperative complications, and recipients' survival was similar ( p =0.455). In very few high-volume centers, robotic right lobe procurement has shown to be a safe procedure. Despite an increased operative and the first warm ischemia times, this approach is associated with reduced intraoperative blood losses and pain compared to the laparoscopic and open approaches. Further data are needed to confirm it as a valuable option for the laparoscopic approach in MIDH.

The introduction of laparoscopy in 1989 revolutionized surgical practices, reducing post-operative complications, and enhancing outcomes. Despite its benefits, limitations in laparoscopic tools have led to continued use of open surgery. Robotic-assisted surgery emerged to address these limitations, but its adoption trends and potential impact on open and laparoscopic surgery require analysis.

A retrospective analysis used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases from 2012 to 2021. The study encompassed various abdominal procedures, employing Vector Autoregressive (VAR) models to analyze the dynamic relationships between surgical techniques. The models predicted future trends in open, laparoscopic, and robotic surgery until Q2 of 2025.

The analysis included 360,171 patients across diverse procedures. In urology, robotic surgery dominated prostatectomies (83.1% in 2021) and nephrectomies (55.1% in 2021), while the open approach remained the predominant surgical technique for cystectomies (72.5% in 2021). In general surgery, robotic colectomies were forecasted to surpass laparoscopy, becoming the primary approach by 2024 (45.7% in 2025). Proctectomies also showed a shift towards robotic surgery, predicted to surpass laparoscopy and open surgery by 2025 (32.3%). Pancreatectomies witnessed a steady growth in robotic surgery, surpassing laparoscopy in 2021, with forecasts indicating further increase. While hepatectomies remained predominantly open (70.0% in 2025), esophagectomies saw a rise in robotic surgery, predicted to become the primary approach by 2025 (52.3%).

The study suggests a transformative shift towards robotic-assisted surgery, poised to dominate various minimally invasive procedures. The forecasts indicate that robotic surgery may surpass laparoscopy and open surgery in colectomies, proctectomies, pancreatectomies, and esophagectomies by 2025. This anticipated change emphasizes the need for proactive adjustments in surgical training programs to align with evolving surgical practices. The findings have substantial implications for future healthcare practices, necessitating a balance between traditional laparoscopy and the burgeoning role of robotic-assisted surgery.

The transition from open hepatectomy to minimally invasive techniques has reduced morbidity and mortality. However, laparoscopic liver resection (LLR) requires substantial expertise. Robotic liver resection (RLR) combines minimal invasiveness with open surgical precision. It may facilitate complex procedures without the learning required for LLR. We evaluated RLR outcomes in a limited resource setting and assessed its efficacy and practicality. This retrospective study analyzed 67 robotic hepatectomies conducted from 2020 to 2023. Demographic, perioperative factors, and surgical outcomes were analyzed. Major hepatectomies were required in 46/67 (68.7%) patients who underwent RLR. No open conversions, 30-day mortalities, or readmissions occurred. Complications occurred in 7.4% of patients; major complications occurred in 5.9%. Learning curve analysis showed a negative correlation between operation sequence and operative time. Effective use of robotic technology combined with the expertise of well-trained surgeons facilitates successful execution of RLR with feasible surgical outcomes, even at smaller centers.

Economic impact of robotic liver surgery (RLS) is still a debated issue due to the heterogeneity of liver resections considered and the lack of a rigorous methodology. Therefore, the aim of this study is to perform a time-driven activity-based costing (TD-ABC) comparing the costs of RLS, laparoscopic liver surgery (LLS) and open liver surgery (OLS) in the context of complex liver resections and to compare short term perioperative outcomes.

The institutional databases of two Italian high volume hepatobiliary centres were retrospectively reviewed from February 2021 to April 2022. Patients submitted to major hepatectomies or postero-superior liver resections were selected and divided into three groups according to the approach scheduled (RLS, LLS and OLS) and compared. Major contributors of perioperative expenses were calculated using the TD-ABC model and accurately quantifying each unit resource consumed per patient and the time spent performing each activity. A primary intention-to-treat analysis (ITT-A) including conversions in the RLS and LLS groups was performed.

Forty-seven RLS, 101 LLS and 124 OLS were collected. LLS and RLS showed reduced blood loss, morbidity, mortality and hospital stay compared with open. A trend towards reduced conversion rate in RLS compared to LLS was registered. Total costs associated with RLS were estimated at €10,637 vs. €9,543 for LLS and vs. €13,960 for OLS. The higher intraoperative costs associated with RLS (+153.3% vs. OLS and +148.2% vs. LLS, P<0.001), primarily related to surgical equipment expenses, were slightly offset by the postoperative savings (-56.0% vs. OLS and -29.4% vs. LLS, P<0.001) resulting from significantly reduced hospital stays.

RLS offers economic advantages over OLS, as initial higher costs are offset by better perioperative outcomes. The evolving robotic marketplace is expected to drive down RLS costs, promoting widespread adoption in minimally invasive procedures. Despite its higher costs than LLS, RLS's ability to enhance minimally invasive feasibility makes it a preferred choice for complex cases, reducing the need for conversions.

The applicability of robot-assisted resection for huge hepatocellular carcinoma (HCC) of ≥10 cm remains contentious with limited available data.

This retrospective analysis involved 337 patients who underwent robotic liver resection for HCC by a single surgeon. Propensity score matching (PSM) was employed to compare perioperative indicators between patients with regular and huge HCC.

The regular HCC group exhibited a shorter median operative duration than the huge HCC group. The IWATE criteria revealed higher scores in the huge HCC group than in the regular HCC group. No significant differences were observed between the two groups in Pringle time, drainage tube removal, duration of hospital stays, blood loss volume, blood product transfusion, margin status, conversion rate to open surgery, bile leakage, in-hospital mortality, and reoperation rate.

Robotic liver resection is feasible for huge HCC, with effective perioperative risk management potentially improving outcomes for subsequent minimally invasive surgeries.

ALPPS leads to fast and effective liver hypertrophy. This enables the resection of extended tumors. Conventional ALPPS is associated with high morbidity and mortality. MILS reduces morbidity and the robot adds technical features that make complex procedures safe.

The MD-MILS was screened for patients who underwent rALPPS. Demographic and perioperative data were evaluated retrospectively. Ninety days postoperative morbidity was scored according to the CD classification. The findings were compared with the literature.

Since November 2021, five patients have been identified. The mean age and BMI of the patients were 50.0 years and 22.7 kg/m2. In four cases, patients suffered from colorectal liver metastases and, in one case, intrahepatic cholangiocarcinoma. Prior to the first operation, the mean liver volume of the residual left liver was 380.9 mL with a FLR-BWR of 0.677%. Prior to the second operation, the mean volume of the residual liver was 529.8 mL with a FLR-BWR of 0.947%. This was an increase of 41.9% of the residual liver volume. The first and second operations were carried out within 17.8 days. The mean time of the first and second operations was 341.2 min and 440.6 min. The mean hospital stay was 27.2 days. Histopathology showed the largest tumor size of 39 mm in diameter with a mean amount of 4.7 tumors. The mean tumor-free margin was 12.3 mm. One complication CD > 3a occurred. No patient died during the 90-day follow up.

In the first German series, we demonstrated that rALPPS can be carried out safely with reduced morbidity and mortality in selected patients.