Robotic liver surgery: literature review and current evidence

In the field of minimally invasive surgery, robotic surgery (RS) was introduced to overcome drawbacks in laparoscopic surgery. However, its clinical application in hepatobiliary surgery is not yet standardized. This review analyzed the results of RS to clarify the benefits of robotic liver surgery in comparison with standard laparoscopy. Among 112 publications found in the literature, the 72 most relevant were selected and the following data were extracted: patients characteristics, operative procedures, histopathology, short-term and long-term outcomes, and costs. Twenty-nine articles on robotic liver resections, published in the last five years (2015-2020) and including 1831 patients, were analyzed. Twenty-five comparative studies between robotic and laparoscopic surgery were evaluated to underline the differences in operative outcomes. Eventually, 4 sub-group analyses were conducted on hepatocellular carcinoma, gallbladder cancer, hilar cholangiocarcinoma, and colorectal liver metastases. Almost all the authors reported data on safety, feasibility and oncologic effectiveness of RS reaching comparable results with laparoscopy. However, even if robotic surgery showed longer operative time and higher costs, in selected cases it allowed to increase the rate of minimally invasive approach when compared with laparoscopy. Thus, both open and minimally invasive surgery should be provided in a modern hepatobiliary center, including the robotic approach particularly to complex cases, otherwise very demanding by laparoscopy. In conclusion, different techniques should be tailored to each patient, choosing the minimally invasive approach when possible, enhancing patients’ recovery after surgery, especially in cirrhotic livers and in the context of liver transplantation. Although many centers experienced robotic liver surgery, more and larger studies are necessary to define its real benefits relative to laparoscopy, in order to standardize patient selection criteria and techniques