Abstract
Background.
Controversies exist among liver surgeons regarding clinical outcomes of the laparoscopic versus the robotic approach for major complex hepatectomies. The authors therefore designed a study to examine and compare the perioperative outcomes of laparoscopic left hepatec tomy or extended left hepatectomy (L-LH/L-ELH) versus robotic left hepatectomy or extended left hepatectomy (R-LH/R-ELH) using a large international multicenter collaborative database.
Methods.
An international multicenter retrospective analysis of 580 patients undergoing L-LH/L-ELH or R-LH/R-ELH at 25 specialized hepatobiliary centers worldwide was undertaken. Propensity score-matching (PSM) was used at a 1:1 nearest-neighbor ratio according to 15 perioperative variables, including demographics, tumor characteristics, Child-Pugh score, presence of portal hypertension, multiple resections, histologic diagnosis, and Iwate difficulty grade.
Results.
Before the PSM, 190 (32 %) patients underwent R-LH/R-ELH, and 390 (68 %) patients underwent L-LH/L-ELH. After the matching, 164 patients were identified in each arm without significant differences in demographics, preoperative variables, medical history, tumor pathology, tumor characteristics, or Iwate score. Regarding intra- and postoperative outcomes, the rebotic approach had significantly less estimated blood loss (EBL) (100 ml [IQR 200 ml] vs 200 ml [IQR 235 ml]; p = 0.029), fewer conversions to open operations (n = 4 [2.4 %] vs n = 13, [7.9 %]; p = 0.043), and a shorter hospital stay (6 days [IQR 3 days] vs 7 days [IQR 3.3 days]; p = 0.009).
Conclusion.
Both techniques are safe and feasible in major hepatic resections. Compared with L-LH/L-ELH, R-LH/R-ELH is associated with less EBL, fewer conversions to open operations, and a shorter hospital stay.
Together with improved surgical instrumentation and techniques, better understanding of liver anatomy, and superior perioperative surgical care, hepatobiliary surgery has evolved tremendously during the last three decades.1-3 With these advancements, hepatobiliary surgeons worldwide have gained confidence and technical proficiency in undertaking complex minimally invasive liver resections safely, which has challenged the traditional open approach, leading to a shorter hospital stay and lower rates of perioperative morbidity.4-6 With ongoing technologic innovations in minimally invasive surgery, a worldwide movement toward laparoscopic and robotic liver resections as alternatives to an open approach, including resections for major hepatectomies, is occurring.
Left hepatectomy (LH: resection of Couinaud’s segments 2 to 4) and extended left hepatectomy (ELH: resection of Couinaud’s segments 2 to 5 and 8) 7, 8 are established types of liver resection for benign and malignant disease, as well as for living donor liver transplantation.9, 10 With the various available approaches for LH and ELH, namely open, laparoscopic (L-LH/L-ELH) and robotic (R-LH/R-ELH) choosing the best method may be challenging due to the scarcity of literature available. This may explain why official guidelines have yet to advocate a uniform approach when LH or ELH is undertaken for treatment of liver tumors.
Although difficult maneuverability and long learning curves impede the adoption of complex laparoscopic operations such as L-LH and L-ELH, a minimally invasive approach to liver resection provides salutary benefits compared with an open approach. These benefits include less estimated blood loss (EBL), less pain, reduced morbidity, shorter hospital stay, and earlier recovery.11, 12
The robotic surgical system was developed to overcome technical limitations inherent to laparoscopic surgery while maintaining the advantages conveyed by a minimally invasive approach. Superior visualization with three-dimensional (3D) camera, easy suturing for rapid bleeding control, precise tissue dissection, improved surgeon dexterity in creating bilio-enteric anastomosis, tremor filtration, and stable platform are known advantages of a robotic system over conventional laparoscopy. Together with its increasing availability, especially in developed countries, the growing experience gained in robotic surgery has allowed initial adoption of the robotic approach for major and minor hepatectomies with excellent outcomes.13, 14 Recent multicenter studies also have advocated use of the robotic over the laparoscopic approach for right posterior sectionectomies and right or extended right hepatectomies by showing decreased EBL, shorter hospital length of stay (LOS), and fewer conversions to open surgery.15-17
Although use of the minimally invasive approach, whether robotic or laparoscopic, has shown improved perioperative outcomes for patients undergoing major hepatectomies, the benefits and limitations of each method still are widely debated among liver surgeons, with scarce literature for uniformly advocacy of a single best approach for LH/ELH. In an attempt to shed light on this debate, we designed a study to fairly compare these two minimally invasive surgical approaches. This study was undertaken to examine and compare the perioperative outcomes of L-LH/L-ELH versus R-LH/R-ELH using a large international multicenter collaborative database. Our hypothesis was that robotic LH/ELH is associated with better perioperative outcomes than the laparoscopic approach.
METHODS
This international multicenter retrospective study analyzed 580 patients undergoing L-LH/L-ELH or R-LH/R-ELH at 25 specialized liver centers between 2008 and 2020. All the institutions obtained their respective institutional review board (IRB) approvals according to their local center’s requirements. This study was approved by the Singapore General Hospital IRB, and the need for patient consent was waived. The de-identified data were collected by the individual centers. These data were collated and analyzed centrally at Singapore General Hospital.
Inclusion and Exclusion Criteria
This study enrolled only patients who underwent pure laparoscopic or robot-assisted laparoscopic liver resections. Laparoscopically assisted (hybrid) and hand-assisted laparoscopic resections were excluded. Similarly, patients undergoing donor hepatectomy for liver transplantation and hepatectomy with bilio-enteric anastomoses also were excluded.
Definitions
Both LH and ELH were defined according to the 2000 Brisbane classification.15 Left hepatectomy included resection of segments 2, 3, and 4 with or without the middle hepatic vein. Extended left hepatectomy included patients who underwent LH and resection of part or all of segments 5 and/or 8 that did not necessarily entail a complete trisectionectomy. Notably, as defined by the Institut Mutualiste Montsouris (IMM) system, LH and ELH may include resections involving the caudate lobe.18
The diameter of the largest lesion was used in the cases of multiple tumors. Postoperative complications were classified according to the Clavien-Dindo classification system and recorded for up to 30 days or during the same hospitalization.19 Difficulty of the liver resections was graded according to the Iwate score.20, 21
Statistical Analysis
Propensity score-matching (PSM) was implemented using a 1:1 nearest-neighbor matching algorithm without replacement, with distance determined by logistic regression. The PSM was performed based on the following variables: gender, age at operation, American Society of Anesthesiology (ASA) status, tumor size, single or multiple tumors, malignant or benign tumors, Child-Pugh score, presence of portal hypertension, previous liver or abdominal operations, whether the hepatectomy was extended, multiple resections, concomitant non-cholecystectomy operation, presence of cirrhosis, histologic diagnosis, and Iwate difficulty grade. Covariate distributions between patients undergoing robotic or laparoscopic LH/ELH were found to be balanced after conditioning on the propensity score (Fig. S1).
In the unmatched cohort, comparisons of patient characteristics and peri- and postoperative details between the patients undergoing robotic and the patients undergoing laparoscopic right hepatectomy were performed using the Mann-Whitney U test for continuous variables and Pearson’s chi-square test for categorical variables. Comparisons in the matched cohorts took the paired nature of the data into account. Therefore, paired analyses such as the Wilcoxon signed-rank test was used for continuous variables, the McNemar chi-square test for 2 X 2 categorical variables, and the McNemar-Bowker chi-square test for 3 X 3 categorical variables. All analyses were performed using R-4.0.0 with package “MatchIt,” and P values lower than 0.05 were considered to indicate statistical significance.
RESULTS
The inclusion criteria were met by 580 patients: 347 (60%) men and 233 women (40 %). The proportion of robotic cases managed, stratified by geographical location, included 134 (70.5 %) in Asia, 10 (5.3 %) in Europe, and 46 (24.2 %) in the Americas, whereas the laparoscopic cases included 188 (48.2 %) in Asia, 186 (47.7 %) in Europe, and 16 (4.1 %) in the Americas. Comparison between the proportion of robotic and laparoscopic operations performed before and after 2015 demonstrated no significant historical bias before (Fig. 1) or after PSM (Fig. 2). Comparison between R-LH/R-ELH and L-LH/L-ELH in the entire unmatched cohort is summarized in Tables 1 and 2.
FIG. 1.
Distribution of cases before and after 2015 in the overall cohort
FIG. 2.
Distribution of cases before and after 2015 in the matched cohort
TABLE 1.
Comparison of clinicopathologic characteristics between RLH and LLH
| Entire cohort (n = 580) n (%) |
Unmatched cohort (n = 580) |
1:1 Propensity-matched cohort (n = 328) |
|||||
|---|---|---|---|---|---|---|---|
| R-LH/R-ELH (n = 190) n (%) |
L-LH/L-ELH (n = 390) n (%) |
p Value | R-LH/R-ELH (n = 164) n (%) |
L-LH/L-ELH (n = 164) n (%) |
p value | ||
| Median age: years (IQR) | 62 (17) | 62 (17) | 63 (17) | 0.949 | 62 (17.3) | 63 (15) | 0.898 |
| Male sex | 347 (59.8) | 112 (58.9) | 235 (60.3) | 0.832 | 100 (61.0) | 105 (64) | 0.648 |
| ASA score | |||||||
| 1/2 | 410 (70.7) | 121 (63.7) | 289 (74.1) | 0.013 | 104 (63.4) | 101 (61.6) | 0.820 |
| 3/4 | 170 (29.3) | 69 (36.3) | 101 (25.9) | 60 (36.6) | 63 (38.4) | ||
| Previous abdominal surgery | 209 (36) | 50 (26.3) | 159 (40.8) | <0.001 | 41 (25) | 38 (23.2) | 0.796 |
| Previous liver surgery | 27 (4.7) | 6 (3.2) | 21 (5.4) | 0.325 | 5 (3.0) | 9 (5.5) | 0.413 |
| Malignant pathology | 455 (78.4) | 140 (73.7) | 315 (80.8) | 0.066 | 131 (79.9) | 136 (82.9) | 0.570 |
| Pathology type | |||||||
| HCC | 200 (34.5) | 75 (39.5) | 125 (32.0) | <0.001 | 69 (42.1) | 66 (40.2) | 0.851 |
| CRM/other mets | 160 (27.6) | 33 (17.4) | 127 (32.6) | 32 (19.5) | 30 (18.3) | ||
| Others | 220 (37.9) | 82 (43.2) | 138 (35.4) | 63 (38.4) | 68 (41.5) | ||
| Cirrhosis | 95 (16.4) | 33 (17.4) | 62 (15.9) | 0.742 | 26 (15.9) | 33 (20.1) | 0.388 |
| Childs Pugh score | |||||||
| No cirrhosis | 484 (83.4) | 157 (82.6) | 327 ( 83.2) | 0.002 | 138 (84.1) | 131 (79.9) | 0.388 |
| A | 90 (15.5) | 27 (14.2) | 63 (16.2) | 26 (15.9) | 33 (20.1) | ||
| B | 6 (1.0) | 6 (3.2) | 0 (0) | 0 (0) | 0 (0) | ||
| Portal hypertension | 22 (3.8) | 8 (4.2) | 14 (3.6) | 0.892 | 2 (1.2) | 7 (4.3) | 0.174 |
| Median tumor size: mm (IQR) | 40 (39.8) | 45 (35) | 40 (40) | 0.865 | 46.5 (30) | 41 (42.8) | 0.660 |
| Multiple tumors | 111 (19.1) | 24 (12.6) | 87 (22.3) | 0.008 | 24 (14.6) | 28 (17.1) | 0.650 |
| Multiple resections | 35 (6.0) | 5 (2.6) | 30 (7.7) | 0.027 | 5 (3.0) | 5 (3.0) | 1 |
| Concomitant operation non-cholecystectomy | 89 (15.3) | 33 (17.4) | 56 (14.4) | 0.412 | 28 (17.1) | 25 (15.2) | 0.764 |
| Left hepatectomy | 526 (90.7) | 176 (92.6) | 350 (89.7) | 0.332 | 150 (91.5) | 148 (90.2) | 0.848 |
| Extended left hepatectomy | 54 (9.3) | 14 (7.4) | 40 ( 10.3) | 14 (8.5) | 16 (9.8) | ||
| Iwate score | |||||||
| Low | 0 (0) | 0 (0) | 0 (0) | 0.009 | 0 (0) | 0 (0) | 0.133 |
| Intermediate | 42 (7.2) | 8 (4.2) | 34 (8.7) | 8 (4.9) | 15 (9.1) | ||
| High | 405 (69.8) | 148 (77.9) | 257 (65.9) | 127 (77.4) | 112 (68.3) | ||
| Expert | 133 (22.9) | 34 (17.9) | 99 (25.4) | 29 (17.7) | 37 (22.6) | ||
Significant values are given in bold (p < 0.05)
RLH, robotic left hepatectomy; LLH, laparoscopic left hepatectomy; R-LH/R-ELH, robotic left hepatectomy or extended left hepatectomy; L-LH/L-ELH, laparoscopic left hepatectomy or extended left hepatectomy; IQR, interquartile range; ASA, American Society of Anesthesiology; HCC, hepatocellular carcinoma; CRM, colorectal liver metastasis
TABLE 2.
Comparison between perioperative outcomes of R-LH/R-ELH vs L-LH/L-ELH
| Entire cohort (n = 580) n (%) |
Unmatched cohort (n = 580) |
1:1 Propensity-matched cohort (n = 328) |
|||||
|---|---|---|---|---|---|---|---|
| R-LH/R-ELH (n = 190) n (%) |
L-LH/L-ELH (n = 390) n (%) |
p value | R-LH/R-ELH (n = 164) n (%) |
L-LH/L-ELH (n = 164) n (%) |
p value | ||
| Median operating time: min (IQR) | 273 (135.3) | 271.5 (135) | 275 (135.5) | 0.407 | 273.5 (131) | 273.5 (149.3) | 0.892 |
| Median blood loss: ml (IQR) | 150 (250) | 100 (168.8) | 200 (270) | 0.005 | 100 (200) | 200 (235) | 0.029 |
| Blood loss (categories) (ml) | |||||||
| <500 ml | 483 (83.3) | 169 (88.9) | 314 (80.5) | 0.0149 | 146 (89.0) | 141 (86.0) | 0.504 |
| ≥500 ml | 97 (16.7) | 21 (11.1) | 76 (19.5) | 18 (11.0) | 23 (‘4.0) | ||
| Intraoperative blood transfusion | 39 (6.7) | 11 (5.8) | 28 (7.2) | 0.652 | 11 (6.7) | 13 (7.9) | 0.832 |
| Pringle maneuver applied | 211 (36.7) | 66 (34.7) | 145 (37.7) | 0.553 | 49 (29.9) | 61 (37.2) | 0.198 |
| Median Pringle duration when applied: min (IQR) | 30 (35.5) | 25 (25) | 36 (40) | 0.035 | 35 (30) | 40 (35) | 0.265 |
| Open conversion | 38 (6.6) | 4 (2.1) | 34 (8.7) | 0.002 | 4 (2.4) | 13 (7.9) | 0.043 |
| Median postoperative stay: days (IQR) | 6 (3.2) | 6 (4) | 6 (3) | 0.279 | 6 (3) | 7 (3.3) | 0.009 |
| 30-Day readmission | 25 (4.3) | 14 (7.4) | 11 (2.8) | 0.022 | 9 (5.5) | 5 (3.0) | 0.413 |
| Postoperative morbidity | 104 (17.9) | 35 (18.4) | 69 (17.7) | 0.921 | 26 (15.9) | 27 (16.5) | 1 |
| Major morbidity (Clavien-Dindo grade ≥ 2 | 40 (6.9) | 10 (5.3) | 30 (7.7) | 0.363 | 6 (3.7) | 13 (7.9) | 0.156 |
| Reoperation | 7 (1.2) | 1 (0.5) | 6 (1.5) | 0.436 | 1 (0.6) | 2 (1.2) | 1 |
| 30-Day mortality | 4 (0.7) | 1 (0.5) | 3 (0.8) | 1 | 1 (0.6) | 1 (0.6) | 1 |
| In-hospital mortality | 3 (0.5) | 1 (0.5) | 2 (0.5) | 1 | 1 (0.6) | 1 (0.6) | 1 |
| 90-Day mortality | 9 (1.6) | 2 (1.1) | 7 (1.8) | 0.725 | 2 (1.2) | 3 (1.8) | 1 |
| Close/involved margins (B1 mm) for malignancies | 64 (11) | 12 (6.3) | 52 (13.4) | 0.016 | 12 (7.3) | 16 (9.8) | 0.553 |
Significant values are given in bold (p < 0.05)
R-LH/R-ELH, robotic left hepatectomy or extended left hepatectomy; L-LH/L-ELH, laparoscopic left hepatectomy or extended left hepatectomy; IQR, interquartile range
Before matching, of the 580 patients who met the inclusion criteria, 190 (32 %) underwent R-LH/R-ELH and 390 (68 %) underwent L-LH/L-ELH. The mean age was 62 years (IQR, 17 years). The R-LH/R-ELH and L-LH/L-ELH treatments differed significantly in terms of ASA classes 3 and 4 (n = 69 [36 %] vs n = 101 [26 %]; p = 0.013), previous abdominal operations (n = 50 [26.3 %] vs n = 159 [40.8 %]; p < 0.001), pathology type (HCC: n = 75 [40 %] vs n = 125 [32 %]), metastasis (n = 33 [17 %] vs n = 127 32 %]), other (n = 82 [43 %] vs n = 138 [35 %]; p < 0.001), Child-Pugh score (Child’s A: n = 27 [14 %] vs n = 63 [16 %]; Child’s B (n = 6 [3 %] vs n = 0] [p = 0.002]), multiple tumors (n = 24 [13 %] vs n = 87 [22 %]; p = 0.008), and IWATE scores (intermediate: n = 8 [4 %] vs n = 34 [9 %]; high: n = 148 [78 %] vs n = 257 [66 %]; expert: n = 34 [18 %] vs n = 99 [25 %] [p = 0.009]).
Pre-matching intraoperative variables showed significant differences between R-LH/R-ELH vs L-LH/L-ELH in median EBL (100 ml [IQR 168.8 ml] vs 200 ml [IQR 270 ml]; p=0.005], median duration of Pringle maneuver when applied (25 min [IQR, 25 min] vs 36 min [IQR 40 min]; p = 0.035], conversion to open operation (n = 4 [2.1 %] vs n = 34 [8.7 %]; p = 0.002), 30-day readmission (n = 14 [7.4 %] vs n = 11 [2.8 %]; p = 0.022), and close/involved margins (n = 12 [6.3 %] vs n = 52 [13.4 %]; p = 0.016).
After PSM, each arm of the study had 164 patients, without significant differences in demographics, preoperative variables, medical history, tumor pathology, tumor characteristics, or Iwate score (Table 1). The intra- and postoperative outcome variables of the R-LH/R-ELH versus the L-LH/L-ELH treatment showed significantly less EBL (100 ml [IQR 200 ml] vs 200 ml [IQR 235 ml]; p = 0.029), lower rate of conversion to open operation (n = 4 [2.4 %] vs n = 13 [7.9 %]; p = 0.043), and shorter hospital stay (6 days [IQR 3 days] vs 7 days [IQR 3.3 days]; p = 0.009]) in favor of the robotic approach (Table 2).
DISCUSSION
Minimally invasive hepatobiliary surgery has evolved to a point that allows surgeons to undertake technically demanding liver resections routinely and enables patients to have a safer and faster postoperative course.4, 9, 11, 13 These minimally invasive techniques (the robotic and laparoscopic approaches) are constantly challenged against open operations and against each-other. Although the robotic approach may overcome many technical short-comings of the laparoscopic approach, its availability, learning curve, and cost has drawn scrutiny of its legitimacy in complex hepatobiliary operations. With the multiple approaches available, no single method has unanimously surpassed the others for clear advocacy of its application over its competitors.
Published data on the modern literature are scarce and limited mainly to small unmatched single-institution series. This is the first large multicenter, international, propensity score-matched study to compare the robotic and laparoscopic approaches regarding the perioperative outcomes of LH/ELH for patients undergoing a curative-intent treatment for liver tumors.
The majority of the matched population in our study consisted of adult men with a malignant pathology and without cirrhosis who underwent a high- or expert-level Iwate-score liver resection. To reduce confounding, we matched the patients undergoing R-LH/R-ELH at a 1:1 ratio to the patients undergoing L-LH/L-ELH based on 15 perioperative variables. Our results showed a superior clinical outcome associated with the robotic approach in terms of EBL (100 ml [IQR 200 ml] vs 200 ml [IQR 235]; p = 0.029], rate of conversion to open operation (n = 4 [2.4 %] vs n = 13 [7.9 %]; p = 0.043), and duration of hospital stay (6 days [IQR 3 days] vs 7 days [IQR 3.3 days]; p = 0.009]. Nonetheless, it is important to note that the difference of 100 ml in blood loss, although statistically significant, was unlikely to be clinically relevant becauses it did not translate into an increase in blood transfusion rate or morbidity. Similarly, the shorter hospital stay associated with the robotic approach in this international study may have been the result of regional differences in hospital stay because local culture and health care systems are well-known to have a major influence on postoperative stay.17
Notably, a higher proportion of robotic cases than laparoscopic cases were managed in the Americas, and the length of stay tended to be shorter than in the other countries. On the contrary, a higher proportion of robotic cases than laparoscopic cases were also performed in Asia, whereby the length of stay is known to be longer than in the other countries.
The lower open conversion rate associated with the robotic approach observed in this study is consistent with that in previous studies. Tsung et al.22 performed a 1:2 matched study comparing robotic with laparoscopic hepatectomies and demonstrated that the robotic approach was associated with a significantly higher proportion of cases managed via a pure minimally invasive approach without the need for hand assistance. Similarly, the recent international multicenter analysis from our group examining robotic versus laparoscopic right posterior sectionectomy matched 88 patients to each arm at a 1:1 ratio and found that the robotic approach was associated with a decreased median EBL (200 vs 400 ml; p < 0.001), fewer intraoperative blood transfusions (n = 9 [10 %] vs n = 21 [24 %]; p = 0.014), and fewer conversions to open operations (n =2 [2.3 %] vs n = 10 [11 %]; p = 0.016).15 Another multicenter study by Chong et al.17 comparing robotic and laparoscopic right hepatectomies reported a lower open conversion rate and a shorter stay in favor of the robotic approach. Cipriani et al.23 performed an Italian multicenter study comparing pure laparoscopic with robotic hepatectomies based on the difficulty scores and similarly found that the robotic group exhibited fewer cases of intraoperative blood loss, fewer transfusions, and lower conversion rates (especially for oncologic radicality) than the laparoscopic group in the setting of highly difficult operations. A small retrospective study by Cai et al.24 comparing 25 robotic and 27 laparoscopic left hepatectomies also showed that the robotic approach was associated with less EBL and a lower incidence of blood product transfusions, but at the expense of an increase in overall costs.
Nevertheless, the advantages of robotic hepatectomy over laparoscopy remain contentious because several other studies have reported no difference between the two approaches. A recent systematic review and meta-analysis by Hu et al.25 comparing robotic and laparoscopic hepatectomies included six studies with a total of 1093 patients (345 robotic [31 %] vs 748 laparoscopic [69 %] approaches). The authors showed heterogeneity of pooled data without a clear benefit to either approach regarding EBL, blood transfusion, resection margins, hospital stay, or postoperative complications. Similarly, the systematic review by Ziogas et al.2 comparing 300 laparoscopic and 225 robotic major hepatectomies concluded that the two approaches were associated with equivalent perioperative outcomes such as open conversion rate, morbidity, blood loss, blood transfusion rate, and length of stay. Finally, in a study by Kamel et al.14 using the National Cancer Data-base, the authors showed that of more than 11,000 hepatectomies undertaken in 621 hospitals in the United States, 25 % were performed by minimally invasive procedures (2.5 % robotically and 22.5 % laparoscopically), with superior outcomes versus an open approach, specifically, a shorter stay, fewer 30-day re-admissions, and lower 90-day mortality. After a propensity score match consisting of 184 patients undergoing robotic hepatectomy and 182 patients undergoing laparoscopic hepatectomy, the authors reported no differences in hospital stay, 30-day readmissions, or 90-day mortality.
To date, whereas the majority of published data regarding robotic versus laparoscopic hepatectomy entail comparison of minor hepatectomies, our study examined the use of minimally invasive approaches for major hepatectomies, namely, LH and ELH. Our study encompassed a considerable intermixture of experienced hepatobiliary surgeons worldwide and showed perioperative advantages favoring the robotic approach, including less EBL, fewer conversions to open operations, and shorter hospital stays. Although studies examining the differences in robotic versus laparoscopic minor hepatectomy and low- versus intermediate-difficulty resections failed to show superiority of one method, the advantage of using the robotic approach to tackle more technically complex and demanding operations such as formal LH and ELH is becoming clearer.15-17, 23 Congruent to this result, our study echoed the technical advantages of complex major hepatectomies associated with the robotic platform, namely, less blood loss and fewer conversions to an open approach. The robotic system facilitates fine tissue and vessel dissections, which allow easy suturing for rapid hemostasis during deep liver parenchymal transection. Ability to promptly control major bleeding, the most common cause of unplanned conversion in major hepatectomy, is increased with the use of the robotic platform. We believe these unique advantages lead to less blood loss and a lower rate of open conversions in the robotic group, which can ultimately affect the hospital length of stay in a favorable direction. Significant intraoperative blood loss and emergent open conversion are known to prolong postoperative recovery and increase morbidities after hepatobiliary operations.
The limitations of the study included its inherent retrospective nature and lack of randomization, which may signify an information and selection bias. Although a nearest-neighbor PSM by 15 perioperative variables was used to minimize this bias, residual selection bias from unknown confounders was inevitable without randomization. As an international multicenter study, the diversity in surgical technique between surgeons may have confounded the results as well. However, the generalizability and external validity of this diversity offer some insight into real-world daily practice.
Another potential confounder, especially with regard to the open conversion rate, was the impact of individual surgeon experience within each center, which was not known in this study. It is conceivable that more experienced liver surgeons with a focus on minimally invasive liver resections were more likely to perform robotic surgery compared with laparoscopic surgery, especially with the limited accessibility of the robotic platform compared with laparoscopy. Nonetheless, despite these limitations, our study provided a strong scientific comparison between robotic and laparoscopic LH/ELH in a large study population.
CONCLUSION
Both the laparoscopic and robotic techniques are valid options for major left-sided liver resections with excellent outcomes. After a propensity score-matched analysis of LH and ELH, the robotic approach was associated with less intraoperative blood loss, fewer conversions to open operations, and a shorter hospital stay.
Supplementary Material
ACKNOWLEDGEMENT
International robotic and laparoscopic liver resection study group investigators: Chung-Yip Chan (Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore); Mizelle D’Silva (Department of Surgery, Seoul National University Hospital Bundang, Seoul National University College of Medicine, Seoul, Korea); Henri Schotte (Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium); Celine De Meyere (Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium); Felix Krenzien (Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Corporate Member of Freie Universität Berlin, and Berlin Institute of Health, Berlin, Germany); Moritz Schmelzle (Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Corporate Member of Freie Universität Berlin, and Berlin Institute of Health, Berlin, Germany); Prashant Kadam (Department of Hepatopancreatobiliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK); Roberto Montalti (Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Federico II University Hospital Naples, Naples, Italy); Qu Liu (Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China); Kit-Fai Lee (Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China; Diana Salimgereeva (Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia); Ruslan Alikhanov (Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia); Lip Seng Lee (Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore); Mikel Gastaca (Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Bilbao, Spain); Jae Young Jang (Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea); Chetana Lim (Department of Digestive, HBP and Liver Transplantation, Hopital Pitie-Salpetriere, APHP, Sorbonne Université, Paris, France); Kevin P. Labadie (Department of Surgery, University of Washington Medical Center. Seattle, WA, USA)
FUNDING
Dr. Kingham was partially supported by the US National Cancer Center Institute MSKCC Core Grant Number P30 CA008747 for this study.
Footnotes
DISCLOSURE Dr Brian K. P. Goh has received travel grants and honorarium from Johnson and Johnson and Transmedic, the local distributor for the Da Vinci robot. Dr Marco V. Marino is a consultant for CAVA robotics LLC. Johann Pratschke reports a research grant from Intuitive Surgical Deutschland GmbH and personal fees or non-financial support from Johnson & Johnson, Medtronic, AFS Medical, Astellas, CHG Meridian, Chiesi, Falk Foundation, La Fource Group, Merck, Neovii, NOGGO, pharma-consult Peterson, and Promedicis. Moritz Schmelzle reports personal fees or other support outside of the submitted work from Merck, Bayer, ERBE, Amgen, Johnson & Johnson, Takeda, Olympus, Medtronic, Intuitive. Fernando Rotellar reports speaker fees and support outside the submitted work from Integra, Medtronic, Olympus, Corza, Sirtex and Johnson & Johnson. The remaining authors haved no conflicts of interest.
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