Robotic versus open hepatectomy for large(≥ 5 cm) hepatocellular carcinoma: A large volume center, propensity score matched study

Abstract

Background

Robotic hepatectomy is widely used to treat liver tumors. However, there are limited studies comparing robotic hepatectomy with conventional open hepatectomy for large (≥ 5 cm) hepatocellular carcinoma. This study aims to evaluate the perioperative and long-term outcomes of patients with large and huge hepatocellular carcinoma undergoing robotic or open hepatectomy.

Methods

This retrospective study included patients with large hepatocellular carcinoma who underwent robotic hepatectomy or open hepatectomy by the same surgical team at the Department of Hepatobiliary Surgery, the First Affiliated Hospital of Guangxi Medical University, from January 2021 to January 2024. Propensity score matching (PSM) was used to minimize potential bias.

Results

According to the predetermined inclusion criteria, this study included 96 open hepatectomy(OH) patients and 23 robotic hepatectomy (RH) patients. After PSM, two homogeneous groups (RH and OH, n = 23 each) were created. The RH group had less blood loss (median 100 ml vs. 300ml, P = 0.008) and a lower incidence of postoperative pulmonary complications (8.7% vs. 39.1%, P = 0.016) compared to the OH group. There were no statistically significant differences in overall survival (OS) and disease-free survival (DFS) between the two groups.

Conclusion

For patients with large(≥ 5 cm) hepatocellular carcinoma, robotic hepatectomy provides a safe, feasible and less invasive approach for treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-025-03914-y.

Introduction

By 2025, over 1 million people are estimated to be affected by liver cancer annually [1]. Hepatocellular carcinoma (HCC) is the most common primary liver cancer, ranking as the sixth most common tumor and the third leading cause of cancer-related deaths [2]. Hepatectomy offers a radical treatment for patients with liver cancer. Previous reports suggest that tumor diameter is a risk factor for HCC recurrence, increasing the potential risk of microvascular invasion, vascular invasion, and distant metastasis [3]. However, with advancements in surgical techniques, and more effective perioperative management, the indications for hepatectomy have expanded. Increasingly experienced centers have reported resections of liver tumours larger than 5 cm (large HCC) [4, 5, 6].

In 1991, Reich et al. first performed laparoscopic hepatectomy of benign liver lesions [7]. Since then, laparoscopic hepatectomy has been widely applied to various liver resections. In 2002, Giulianotti et al. first reported robotic-assisted laparoscopic hepatectomy [8]. Subsequently, medical centers worldwide have reported their experiences with robotic hepatectomy. The robotic-assisted laparoscopic system offers several advantages, including a clear, stable, and magnified view, better flexibility, more ergonomic instruments, and tremor filters [9].

Although reports of robotic hepatectomy have increased, few studies compare robotic hepatectomy with open hepatectomy, especially for liver cancers larger than 5 cm [10]. The therapeutic efficacy of robotic hepatectomy for large(≥ 5 cm) HCC remains controversial. Particularly with regard to their impact on survival time and postoperative complications. This study used propensity score matching (PSM) to compare the therapeutic effects of robotic hepatectomy and open surgery in patients with large and huge HCC, evaluating their efficacy and safety. As a same surgical team report, this study provides new references for the clinical treatment of patients with large and huge HCC.

Methods

Patients

A retrospective analysis was conducted on patients who underwent open or robotic hepatectomy by the same surgical team at the First Affiliated Hospital of Guangxi Medical University from January 2021 to January 2024. Inclusion criteria were: (1) age > 18 years; (2) tumor diameter ≥ 5 cm; (3) no severe major organ dysfunction; (4) no history of other malignant tumors; (5) postoperative pathological diagnosis of HCC. Exclusion criteria were: (1) pathological diagnosis of other types of malignant tumors. (2) patients who received interventional, targeted, immunological, or radiotherapy treatments preoperatively.

This study was approved by the local ethics committee (approval number: 2024-E394-01). The study complies with the Declaration of Helsinki. All patients and their families were informed about the study and consented to participate.

Preoperative evaluation

All patients underwent routine clinical examinations, two imaging examinations (ultrasound, CT, or MRI), and laboratory tests, including total bilirubin, serum albumin, prothrombin time, international normalized ratio, alanine aminotransferase, aspartate aminotransferase, hepatitis B surface antigen, hepatitis C surface antibody, and tumor marker AFP. The diagnosis and treatment plan for each patient was determined by a multidisciplinary team. The choice between open and robotic hepatectomy depended on the patient’s condition and preferences, the surgeon’s expertise, the tumor’s size and location, and the availability of equipment. Preoperative data included gender, age, height, body mass index, American Society of Anesthesiologists classification, and key laboratory test results. Staging was determined using the Barcelona Clinic Liver Cancer (BCLC) staging system [11]. The extent of cirrhosis was assessed using the Ishak scoring system [12].

Surgical procedure

From January 2021 to January 2024, our team performed a total of 221 robotic hepatectomy. All resections in this study were performed by two senior surgeons after completing their individual learning curves (≥ 60 robotic hepatectomy cases).

Anterior approach was used both in open and robotic hepatectomy. The systems used for patients undergoing robotic hepatectomy include the da Vinci Xi robot and the da Vinci Si robot. For right hemihepatectomy, a 12 mm trocar was placed at the umbilicus as the assistant’s operating port. The first and fourth robotic arms’ 8 mm trocars were positioned below the costal margin at the right and left anterior axillary lines, respectively. An 8 mm trocar for the third robotic arm was placed between the fourth robotic arm and the assistant’s port. A 12 mm trocar was positioned at the midpoint between the right anterior axillary line and the midline at the umbilical level as the camera port. The second robotic arms’ 8 mm trocars were positioned above the camera port (Fig. 1A). For left hemihepatectomy, a 12 mm trocar was placed at the umbilicus as the camera port. Another 12 mm trocar was positioned at the midpoint between the right anterior axillary line and the midline at the umbilical level as the assistant’s operating port. The first, second, and fourth robotic arms were positioned below the costal margin at the right anterior axillary line, at the camera port, and below the costal margin at the left anterior axillary line, respectively. The third robotic arm was positioned between the fourth robotic arm and the camera port (Fig. 1B). The anatomical separation during robotic right hemihepatectomy and left hemihepatectomy is shown in Fig. 2. Open liver resection surgery employs an anterior approach: a reverse L-shaped incision was used. The operational steps of the two methods are similar. Intraoperative ultrasound reassesses the tumor’s location, size, number, and positions of adjacent blood vessels, especially the anatomical relationships of the right, middle, and left hepatic veins. In right hemihepatectomy, cholecystectomy was performed firstly. The hepatic artery and portal vein were dissected individually and divided. Ultrasonic scalpel was used for liver parenchyma transection with low CVP. The Pringle maneuver is used, with intermittent clamping for 15 min followed by 5 min of reperfusion. The left/right hepatic vein was divided by surgical stapler. The specimen was removed. The surgical field was examined. Abdominal drainage was put in the surgical field.

Fig. 1.

The placement of the trocars in the da Vinci Xi robot system is illustrated in the figure. (A) Distribution of trocar positions for right hemihepatectomy. The yellow-marked area indicates the resection range. (B) Distribution of trocar positions for left hemihepatectomy. The yellow-marked area indicates the resection range

Fig. 2.

Intraoperative demonstration of robotic right and left hemihepatectomy. (A) Separation of the right hepatic artery. (B) Separation of the right portal vein. (C) Isolation of the right hepatic duct. (D) Separation of the right hepatic vein. (E) Separation of the left hepatic artery. (F) Separation of the left portal vein. (G) Isolation of the left hepatic duct. (H) Separation of the left hepatic vein

Intraoperative data and pathological results were collected, including operative time, blood loss, transfusion status, tumor size, and vascular invasion. Intraoperative blood loss is calculated from the difference between fluid in the suction canister and abdominal irrigation fluid, plus the weight difference between surgical gauze and dry gauze [13]. Major vascular invasion is defined as the intrahepatic tumor invading branches of the portal vein or hepatic veins, and extrahepatic invasion of the portal vein trunk or inferior vena cava [14]. Microvascular invasion is defined as microscopic tumor invasion identified in the portal vein and hepatic veins of the surrounding liver tissue adjacent to the tumor edge. It refers to the presence of nests of cancer cells (≥ 50 cells) within endothelial cell-lined vascular lumens observed under a microscope [15, 16].

Perioperative outcomes and long-term outcomes

Perioperative outcomes included in the analysis are operative time, blood loss, postoperative stay, complications, and mortality. Postoperative stay is defined as the time from surgery to discharge. Postoperative complications included abdominal hemorrhage, bile leakage, ascites, liver failure, abdominal infection, and pulmonary complications. Abdominal hemorrhage is defined as a postoperative drop in hemoglobin greater than 3 g/dl from baseline and/or the need for transfusion or invasive reintervention to stop bleeding [17]. Bile leakage is defined as the bilirubin concentration in drainage fluid being three times or more the serum bilirubin concentration on or after the third postoperative day [18]. Ascites is defined as the drainage of more than 10 ml/kg of ascitic fluid per day from the abdominal drainage tube [19]. Postoperative liver failure is assessed using the 2011 criteria of the International Study Group of Liver Surgery (ISGLS) [20]. Abdominal infection is defined as the drainage of purulent fluid through the tube, isolation of organisms from sterile fluid or tissue cultures, or the development of abscesses or other evidence of organ space infection identified through direct examination, reoperation, histopathology, or imaging studies [21]. Routine CT scan is performed on the third postoperative day. Pulmonary complications include pneumonia, pleural effusion, atelectasis, and pulmonary embolism identified through CT scan [22]. The severity of postoperative complications is graded using the Clavien-Dindo classification, with Grade III and IV classified as major complications [23, 24].

Long-term outcomes included in the analysis are overall survival (OS) and disease-free survival (DFS). OS is defined as the time interval between surgery and death from any cause or the last follow-up. DFS is defined as the time interval between surgery and the first recorded tumor recurrence. All patients were followed up after discharge, with follow-ups every 3 months during the first year, and every 3 to 6 months thereafter. Routine examinations at each follow-up included complete blood count, liver function tests, tumor markers, immune test, and abdominal ultrasound. CT or MRI was performed if necessary. Recurrence was defined as the appearance of any new intrahepatic or extrahepatic tumor lesions on CT or MRI after hepatectomy. Post-recurrence treatments were selected based on the patient’s condition and individual preferences, and included surgical resection, radiofrequency ablation and microwave ablation, transarterial chemoembolization (TACE), or systemic therapy. The last follow-up was on May 1, 2024.

Statistical analysis

Categorical variables are presented as numbers and percentages, while continuous variables are presented as medians and interquartile ranges. Continuous variables were compared using the Mann-Whitney U test, and categorical variables using the Chi-square test or Fisher’s exact test. Propensity score matching (PSM) was used to eliminate selection bias between the two groups. PSM analysis was performed using a 1:1 ratio based on the nearest neighbor matching method with a caliper set to 0.20. Constructed using a logistic regression model incorporating age, sex, body mass index (BMI), albumin, total bilirubin, platelet, alanine aminotransferase(ALT), aspartate aminotransferase(AST), international normalized ratio(INR), serum α-fetoprotein(AFP), viral hepatitis infection, Child-Pugh grade, Barcelona Clinic Liver Cancer (BCLC) stage, indocyanine green retention rate at 15 min(ICG15), portal hypertension, model for end-stage liver disease (MELD) score, tumor number, tumor size, vascular invasion, and American Society of Anesthesiologists (ASA) classification. Kaplan-Meier (KM) curves were used to analyze OS and DFS, with comparisons made using the log-rank test. A p-value of less than 0.05 was considered statistically significant. All statistical analyses were performed using SPSS version 26.0.

Result

Patient characteristics

Open hepatectomy group had 96 cases, while robotic hepatectomy group had 23 cases. Before matching, there was a statistically significant difference in BCLC stage (P < 0.05) between the two cohorts. After PSM, each group (open and robotic hepatectomy) had 23 patients. The baseline characteristics of the two groups showed no statistically significant differences, and all baseline clinical characteristics were well balanced. Table 1 shows the baseline clinical characteristics of patients with large hepatocellular carcinoma in the open and robotic hepatectomy groups before and after PSM.

Table 1.

Baseline characteristics of patients with large and huge HCC in the robotic group and open group before and after PSM

Variable	Before PSM			After PSM
	Open group (n = 96)	Robotic group (n = 23)	P value	Open group (n = 23)	Robotic group (n = 23)	P value
Age(years)	52.50(47–58)	51.00(42–66)	0.741	53.00(47–56)	51.00(42–66)	0.956
Sex, n(%)
Female	18(18.8)	6(26.1)	0.403	4(17.4)	6(26.1)	0.475
Male	78(81.3)	17(73.9)		19(82.6)	17(73.9)
BMI(kg/m2)	22.50 (20.90-24.76)	23.15 (20. 90-24.61)	0.736	21.63 (19.38–24.22)	23.15 (20. 90-24.61)	0.160
Albumin(g/L)	40.85 (36.90–43.70)	42.40 (37.60–44.70)	0.331	40.80 (36.80–43.70)	42.40 (37.60–44.70)	0.416
Platelet, n(%)
<100 × 109	1(1.0)	0(0)	>0.999	0(0)	0(0)	>0.999
≥ 100 × 109	95(99.0)	23(100)		23(100)	23(100)
Total bilirubin(µmol/L)	10.60 (8.13–14.40)	11.70 (7.70–16.50)	0.520	10.50 (8.40–13.60)	11.70 (7.70–16.50)	0.750
ALT(U/L)	33.50 (20.00–48.00)	29.00(20.00–34.00)	0.174	43.00 (22.00–63.00)	29.00(20.00–34.00)		0.144
AST(U/L)	41.00 (29.00–58.00)	30.00 (23.00–45.00)	0.100	43.00 (29.00–50.00)	30.00 (23.00–45.00)		0.093
INR	1.02 (0.97–1.09)	1.00 (0.96–1.02)	0.099	1.03 (0.98–1.09)	1.00 (0.96–1.02)		0.121
AFP, n(%)
<400	58(60.4)	13(56.5)	0.732	15(65.2)	13(56.5)		0.546
≥ 400	38(56.3)	10(43.5)		8(34.8)	10(43.5)
Viral hepatitis, n(%)
HBV	72(75.0)	18(78.3)	>0.999	19(82.6)	18(78.3)		>0.999
HCV	3(3.1)	0(0)		0(0)	0(0)
Child-Pugh, n(%)
A	96(100)	23(100)	>0.999	23(100)	23(100)		>0.999
B	0(0)	0(0)		0(0)	0(0)
BCLC stage, n(%)
A	51(53.1)	20(87.0)	0.011	15(65.2)	20(87.0)		0.266
B	13(13.5)	1(4.3)		2(8.7)	1(4.3)
C	32(33.3)	2(8.7)		6(26.1)	2(8.7)
ICGR15	4.50 (3.00–6.00)	3.80 (2.10-6.00)	0.076	4.30 (3.00-5.60)	3.80 (2.10-6.00)		0.291
Cirrhosis, n(%)	54(56.3)	9(39.1)	0.140	13(56.5)	9(39.1)	0.238
Portal hypertension, n(%)	28(29.2)	5(21.7)	0.475	6(26.1)	5(21.7)	0.730
MELD score	5.00 (4.00–7.00)	5.00 (4.00–6.00)	0.651	5.00 (4.00–7.00)	5.00 (4.00–6.00)		0.850
Number of tumour, n(%)
1	87(90.6)	23(100)	0.203	21(91.3)	23(100)		0.489
≥ 2	9(9.4)	0(0)		2(8.7)	0(0)
Tumor size(cm)
<10	58(60.4)	16(69.6)	0.416	21(91.3)	16(69.6)		0.135
≥ 10	38(39.6)	7(30.4)		2(8.7)	7(30.4)
MVI, n(%)	42(43.8)	11(47.8)	0.724	8(34.8)	11(47.8)		0.369
MaVI, n(%)	21(21.9)	2(8.7)	0.239	6(26.1)	2(8.7)		0.243
ASA grades, n(%)
≤II	64(66.7)	15(65.2)	0.895	16(69.6)	15(65.2)		0.753
>II	32(33.3)	8(34.8)		7(30.4)	8(34.8)

Abbreviation: HCC, hepatocellular carcinoma; PSM, propensity score matching; BMI, body mass index; ALT, alanine aminotransferase; AST, aspartate aminotransferase; INR, international normalized ratio; AFP, α-fetoprotein; HBV, hepatitis B virus; HCV, hepatitis C virus; BCLC stage, Barcelona Clinic Liver Cancer stage; ICGR15, indocyanine green retention rate at 15 min; MELD, Model for end-stage liver disease; MVI, Microvascular invasion; MaVI, macrovascular invasion; ASA, American Society of Anesthesiologists

Perioperative outcomes

Table 2 shows the surgical outcomes of patients with large hepatocellular carcinoma in the open and robotic hepatectomy groups before and after PSM. After PSM, there were no statistically significant differences between the open and robotic hepatectomy groups in terms of operative time, resection extent, transfusion status, and postoperative hospital stay. However, the robotic group had less intraoperative blood loss (median 100 ml vs. 300 ml, P < 0.05) and a lower incidence of postoperative pulmonary complications (8.7% vs. 39.1%, P < 0.05). Table 2 details the perioperative outcomes before and after PSM. The type of hepatic resection for all patients is listed in Table S1.

Table 2.

Perioperative outcomes of patients with large HCC in the robotic group and open group before and after PSM

Variable	Before PSM			After PSM
	Open group (n = 96)	Robotic group (n = 23)	P value	Open group (n = 23)	Robotic group (n = 23)	P value
Operative time(min)	241.00 (203.00-303.00)	280.00 (207.00-320.00)	0.383	250.00 (200.00-303.00)	280.00 (207.00-320.00)	0.455
Blood loss (mL)	300.00 (112.50-587.50)	100.00 (100.00-300.00)	0.002	300.00 (100.00-600.00)	100.00 (100.00-300.00)	0.008
Intraoperative blood transfusion, n(%)	67(69.8)	15(65.2)	0.670	17(73.9)	15(65.2)	0.522
Type of resection, n (%)			0.615			0.430
Right hemihepatectomy	10(10.4)	4(17.4)		1(4.3)	4(17.4)
Left hemihepatectomy	24(25.0)	6(26.1)		8(34.8)	6(26.1)
Other segement resection	62(64.6)	13(56.5)		14(60.9)	13(56.5)
Complications, n (%)
Intra-abdominal infection	0(0)	0(0)	>0.999	0(0)	0(0)	>0.999
Ascites	19(19.8)	2(8.7)	0.360	3(13.0)	2(8.7)	>0.999
Bile leakage	2(2.1)	0(0)	>0.999	0(0)	0(0)	>0.999
Intra-abdominal bleeding	9(9.4)	1(4.3)	0.685	2(8.7)	1(4.3)	>0.999
Liver failure	2(2.1)	1(4.3)	0.478	0(0)	1(4.3)	>0.999
Pulmonary complication	19(19.8)	2 (8.7)	0.360	9(39.1)	2 (8.7)	0.016
Clavien-Dindo grade≥III,n(%)	7(7.3)	1(4.3)	>0.999	0(0)	1(4.3)	>0.999
Postoperative stay(days)	7.00 (6.00–11.00)	7.00 (6.00–9.00)	0.303	8.00 (6.00–11.00)	7.00 (6.00–9.00)	0.244

Abbreviation: HCC, hepatocellular carcinoma; PSM, propensity score matching

Long-term outcomes

In the long-term outcomes after PSM, the median OS for open hepatectomy group was 28.27 months, and the DFS was 25.93 months. The median OS for robotic hepatectomy group was 25.17 months, and the DFS was 19.60 months. Both groups had similar OS(P = 0.083) and DFS(P = 0.487). The Kaplan-Meier curves for OS and DFS of the two groups are shown in Fig. 3. The numbers-at-risk table shows the following. OS: 23 vs. 22 patients at 10 months, 21 vs. 13 at 20 months, 9 vs. 9 at 30 months, and 1 vs. 1 at 40 months (OH vs. RH). DFS: at 10, 20, 30, and 40 months, the OH/RH numbers at risk were 21/20, 16/12, 8/9, and 1/1, respectively.

Fig. 3.

Kaplan–Meier curves estimating OS and RFS of HCC patients after PSM

Discussion

In recent years, significant changes in treatment modalities for HCC, including liver resection, liver transplantation, TACE, transarterial radioembolization (TARE), Immunotherapy and targeted therapy, have greatly improved the outcome [25]. Despite these advances, hepatectomy remains the critical treatment for HCC [26]. For patients with large or huge HCC, treatment options are limited. Liver transplantation is not applicable because it does not meet the Milan criteria [27, 28]. Percutaneous treatments are more suitable for tumors smaller than 5 cm in diameter [29]. The exact efficacy of systemic therapies still requires further investigation [30]. Studies have shown that liver resection offers better prognostic outcomes than TACE for patients with large and huge HCC [31, 32]. The efficacy of TARE also needs evaluation through larger randomized clinical trials [33]. Although significant progress has been made in immunotherapy and targeted therapy, the enhanced efficacy of combination therapies often comes with a high risk of toxicity. Additionally, the emergence of resistance and disease progression remain significant challenges. There is a continued need to explore more effective combination or sequential approaches to improve treatment outcomes [34, 35, 36].

Anterior approach hepatectomy is the preferred treatment for large and huge HCC, as it provides better surgical and survival outcomes [37, 38, 39].With technological advancements, the benefits of minimally invasive liver resection are widely recognized [40]. Compared with open hepatectomy, laparoscopic hepatectomy performed by experienced surgeons results in significantly fewer complications, shorter hospital stays, and reduced blood loss [41]. However, laparoscopic hepatectomy also has limitations, including difficulties with laparoscopic suturing, instability due to the lever effect, and the inherently limited activity of laparoscopic instruments [42].

Robotic hepatectomy has been promoted and applied in more centers, showing significant advantages over traditional laparoscopic hepatectomy in three-dimensional vision and tremor filtering. These features enable precise tissue dissection and accurate in vivo operations, providing superior control of bleeding points during hilar dissection and liver parenchyma transection. However, the efficacy of minimally invasive liver resection for HCC with a tumor diameter ≥ 5 cm, even ≥ 10 cm remains controversial, and some centers still consider it a relative contraindication [43, 44, 45]. Recently, the efficacy of minimally invasive liver resection for large HCC has been reported in some experienced centers [46, 47, 48]. However, there are still few comparisons of the efficacy of robotic hepatectomy versus open hepatectomy in patients with large HCC, and even fewer studies on these two approaches for treating huge HCC.

Dumronggittigule et al. reported that the long-term survival rate of laparoscopic liver resection in patients with large HCC was comparable to open hepatectomy [47]. Zhang et al. reported in a multicenter study that robotic hepatectomy for large HCC showed advantages in blood loss, postoperative hospital stay, and operative time [48]. These results indicate that minimally invasive liver resection, especially RH, is a safe and feasible treatment for large HCC.

In our study, we used PSM to minimize bias and compare patients undergoing robotic and open hepatectomy for large HCC, analyzing perioperative outcomes and long-term results. After PSM, RH group showed more favorable perioperative outcomes than OH group, mainly in operative blood loss and postoperative pulmonary complications. In long-term outcomes, there were no significant differences in OS and DFS between two groups.

For a long time, surgery duration has been a major concern for surgeons, as it significantly affects patients’ postoperative recovery. The longer the operative time, the more significant the impact on postoperative respiratory function [49]. Pulmonary complications are the most common postoperative complications, with an incidence ranging from 10–80%²². Postoperative pulmonary complications are the main reason for prolonged recovery time and poor prognosis after hepatectomy [50]. In this study, after PSM, blood loss in 23 OH patients was 300 (100–600) ml, and in 23 RH patients, it was 100 (100–300) ml; In the OH group, nine patients (39.1%) developed postoperative pulmonary complications, while two patients (8.7%) in the RH group experienced these issues. The RH group had less blood loss than OH group (P = 0.008). The incidence of pulmonary complications was also lower in the RH group than in OH group(P = 0.016). No significant statistical difference was found in the incidence of severe complications between the two groups. In practice, the docking of the robotic cart and the reconnection during the replacement of surgical instruments consume considerable time, making the total surgery time comparable to open surgery. However, the robotic group had a shorter intra-abdominal operating time than the open surgery group, potentially resulting in less tissue and organ damage. Reduced damage and inflammation could help decrease postoperative pulmonary complications.

In our study, after PSM, there was no statistically significant difference in OS (p = 0.083) and DFS (p = 0.487) between RH and OH groups. The numbers-at-risk tables beneath the Kaplan–Meier curves indicated comparable follow-up durations and censoring patterns in the RH and OH groups. This indicates that RH can be a treatment option for large HCC. Combined with the better performance of RH in blood loss and postoperative pulmonary complications, this suggests that using RH to treat large HCC is safe and feasible. All surgeons in this study had already completed the learning curve for robotic liver resection, which may have contributed to the favorable surgical outcomes. Previous studies indicate that surgical experience affects both operative time and postoperative outcomes in robotic procedures [51].

This study has limitations. First, as a non-randomized retrospective analysis, it is prone to selection bias. We used PSM to minimize this interference. Second, the sample size of RH in this study is limited, necessitating more RH cases to validate its safety and efficacy. Additionally, deficiencies in follow-up duration for some cases may have introduced potential bias into the study results. Third, multiple centers studies are required to compare the long-term outcomes of RH and OH.

Conclusion

In perioperative outcomes, RH has advantages over OH in intraoperative blood loss and the incidence of postoperative pulmonary complications. In long-term prognosis, RH and OH show comparable results. Our study suggests that for patients with large HCC, RH is a safe, feasible and minimally invasive treatment option.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Author contributions

CRediT authorship contribution statement: Weimin Mao: Data curation, Formal analysis, Writing - original draft.Bingcheng Meng: Methodology, Writing - original draft.,Zongrui Jin: Conceptualization, Data curationBanghao Xu: Investigation, MethodologyJilong Wang: Software, SupervisionZhujing Lan: Software, ValidationJingyuan Zhou: Validation, VisualizationTiansheng Lan: Validation, VisualizationTingting Lu: Resources, SoftwareLing Zhang: Resources, SoftwareRui Song: Resources, SoftwareZili Lv: Resources, SoftwareHai Zhu: Conceptualization, Funding acquisition, Supervision, Writing - review & editing.Zhang Wen: Conceptualization, Funding acquisition, Supervision, Writing - review & editing.

Funding

This work was supported by the National Natural Science Foundation of China(Grant No.82160128).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the local ethics committee (Medical ethics committee of the First Affiliated Hospital of Guangxi Medical University, approval number: 2024-E394-01).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.