Robotic vs. laparoscopic liver surgery: what are the advantages of the robot?

Abstract

Background: Laparoscopic liver surgery is safe and feasible. The robot adds some new technical features which might be of advantage in specific cases. But it is unclear if the robot is superior to conventional laparoscopy. For this reason, we summarized the literature of the last 10 years which focused on this issue and compared it with own experiences. Methods: A PubMed research was performed including keywords for laparoscopic and robotic liver surgery. Original articles comparing patients which underwent robotic-assisted liver resection (RLR) vs. laparoscopic liver resection (LLR) were selected for further analysis. Patients which underwent left lateral liver resection with RLR or LLR between 2015–2020 were selected from the Magdeburg registry of minimally invasive liver surgery (MD-MILS). Perioperative outcome from the literature review and own data were analyzed and compared. Results: We identified 29 studies including 1,392 patients which underwent RLR and 1,965 patients which underwent LLR. The mean operative time ranged between 121–425 min in RLR and 130–565 min in LLR. The conversion rates were 0–20% in RLR and 0–30.9% in LLR. In major liver resections the conversation rate in the RLR group were 4.0–14.3% and 4.0–25.0% in the LLR patients. Mean estimated blood loss was 30–500 mL in RLR vs. 30–513 mL in LLR. Blood transfusion was needed in 0–25.0% of patients which underwent RLR and 0–23.1% of patients which were operated as LLR. Perioperative overall morbidity was reported in 0–68.0% in RLR cases and 0–35.3% of LLR. The mortality was 0–10% in the RLR and 0–5% in the LLR cases. Margins with residual tumor (R1) in case of malignancy were present in 0–11.1% of RLR cases and 0–23.1% in LLR procedures. In major liver resections the R1 resection rate were 0–8.3% in RLR and 7.4–25.0% in LLR. Costs were generally calculated higher in RLR vs. LLR and there were no significant differences in disease-free survival (DFS) and overall survival (OAS) in malignancies. The 22 selected cases from MD-MILS showed a mean operation time for RLR of 243.2 [standard deviation (SD) 80.2] vs. 160.1 (SD 39.8) min in LLR (P=0.01). Other perioperative data were not statistically significant different and confirmed the results from the literature. Conclusions: Robotic liver surgery is safe and not inferior to conventional laparoscopy. It might have some advantages in major liver resections regarding decreased conversion rate and less positive margins. This has to be proven in further studies.