Übersicht
Robotic Liver Surgery – Current Standards and Future Perspectives
Robotische Leberchirurgie – Aktuelle Standards und Perspektiven
Authors
Felix Becker, Haluk Morgül, Shadi Katou, Mazen Juratli, Jens Peter Hölzen, Andreas Pascher, Benjamin Struecker
Affiliation
Department of General, Visceral and Transplant Surgery,
University Hospital Münster, Germany
Key words
liver, hepatic resection, robotic surgery, minimal invasive
surgery, laparoscopy
Schlüsselwörter
Leber, Leberresektion, robotische Chirurgie, Minimal invasive
Chirurgie
received 31.10.2020
accepted 03.12.2020
Bibliography
Z Gastroenterol 2021; 59: 56–62
DOI 10.1055/a-1329-3067
ISSN 0044-2771
© 2020. Thieme. All rights reserved.
Georg Thieme Verlag KG, Rüdigerstraße 14,
70469 Stuttgart, Germany
Correspondence
Felix Becker
Department of General, Visceral and Transplant Surgery
University Hospital Münster, Waldeyerstraße 1,
48149 Münster, Germany
Tel.: +49/2 51/8 35 63 01
Fax: +49/2 51/8 35 63 11
felix.becker@ukmuenster.de
Z US A M M E N FA SS U N G
Hintergrund Die robotische Leberchirurgie entwickelt sich
zur Zukunft der minimalinvasiven Chirurgie. Das robotische
Operationssystem bietet eine stabile Kameraplattform, Elimi-
nation des physiologischen Tremors, verbesserte chirurgische
Geschicklichkeit sowie eine entspannte Ergonomie durch
sitzende Position. Aufgrund theoretischer Vorteile des robot-
ergestützten Systems erscheint die Leberchirurgie ein beson-
ders geeignetes Feld für den Einsatz des OP Roboters zu sein,
da es hohe technische Anforderung (delikate vaskuläre und
parenchymatöse Präparation, intrakoroprale Anastomosen,
Blutstillung) an den Chirurgen stellt.
Material und Methoden Durch die Auswertung bestehen-
der englisch- und deutschsprachigen Literatur zur offenen,
56 Becker F et al. Robotic Liver Surgery… Z Gastroenterol 2021; 59: 56–62 | © 2020. Thieme. All rights reserved.
laparoskopischen sowie robotischen Leberchirurgie bietet
diese Übersichtsarbeit einen Überblick über aktuelle Literatur
sowie Standards und zielt darauf ab, zukünftige Entwicklun-
gen der robotischen Leberchirurgie aufzuzeigen.
Ergebnisse Die robotische Leberchirurgie ist ein sicheres und
technisch durchführbares Operationsverfahren. Im Vergleich
zu offener und laparoskopischer Chirurgie zeigen sich verbes-
serte intra- und postoperative Outcome Daten, bei gleichwer-
tigen onkologischen Ergebnissen.
Diskussion In komplexen Fällen, einschließlich größerer
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Hepatektomien, erweiterter Gallenrekonstruktionen und Seg-
mentektomien der hinteren Segmente, stellt sich robotische
Chirurgie mehr als Alternative zur offenen als zur laparoskopi-
schen Chirurgie auf. Damit erweitert sich das Spektrum mini-
malinvasiver Leberchirurgie.
ABSTR AC T
Background Robotic liver surgery is emerging as the future
of minimal invasive surgery. The robotic surgical system offers
a stable camera platform, elimination of physiologic tremor,
augmented surgical dexterity as well as improved ergonomics
because of a seated operating position. Due to the theoretical
advantages of the robotic assisted system, complex liver sur-
gery might be an especially interesting indication for a robotic
approach since it demands delicate tissue dissection, precise
intracorporeal suturing as well as difficult parenchymal tran-
section with subsequent need for meticulous hemostasis and
biliostasis.
Material and methods An analysis of English and German
literature on open, laparoscopic and robotic liver surgery was
performed and this review provides a general overview of the
existing literature along with current standards and aims to
specifically point out future directions of robotic liver surgery.
Results Robotic liver surgery is safe and feasible compared to
open and laparoscopic surgery, with improved short-term
postoperative outcomes and at least non-inferior oncological
outcomes.
Conclusion In complex cases including major hepatectom-
ies, extended hepatectomies with biliary reconstruction and
difficult segmentectomies of the posterior-superior seg-
ments, robotic surgery appears to emerge as a reasonable
alternative to open surgery rather than being an alternative
to laparoscopic procedures.
Introduction
Over the last decades, minimal invasive hepatic resection has
revolutionized the landscape of liver surgery. Various inherent
drawbacks of conventional surgery were attenuated, and mini-
mally invasive approaches in liver surgery have been shown to of-
fer specific advantages including reduced blood loss, fewer inci-
sional hernias, minimized morbidity and postoperative pain,
decreased time to postoperative oral intake, shorter length of
stay and improved cosmesis as well as enhanced cost-effective-
ness. [1]. In addition, a growing body of evidence reveals that
laparoscopic surgery can be superior to conventional open sur-
gery without compromising oncologic outcomes (R0 resection
rate and 5-year overall survival), even for complex malignant dis-
eases such as colorectal liver metastasis or hepatocellular carcino-
ma [2–4]. However, although minimal invasive surgery should be
the standard approach for the majority of hepatic resections,
many centers still perform open liver surgery. This can partly
be explained with intrinsic limitations of the laparoscopic ap-
proach [5]: 1) an unsteady and only two-dimensional view, 2) am-
plification of physiologic tremor, 3) limited mobility due to
straight instruments in combination with a limited range of
motion, 4) poor ergonomics for the surgical team and 5) longer
operation times. Robotic surgery could overcome many of these
limitations and provides the unique chance to complement
laparoscopic approaches in liver surgery; moreover, robotic liver
surgery will challenge open liver resections for indications, cur-
rently doomed as not feasible for a minimal invasive procedure.
The robotic surgical system offers a stable, high-definition and
magnified three-dimensional camera platform, elimination of
physiologic tremor, increased range of motion due to articulated
instruments, recreating the seven-degrees of freedom of the hu-
man wrist, leading to augmented surgical dexterity as well as im-
proved ergonomics due to a seated and comfortable operating
position. These theoretical advantages of robotic surgery initiated
a broad utilization among various surgical specialties [6]. In Ger-
many alone, the overall volume of robotic procedures rose from
4 procedures in 2010 to 819 in 2015 [7]. While feasibility and safe-
ty of robotic surgery were clearly established by retrospective
case series and non-randomized data, subsequent randomized
control trials (RCTs) further demonstrated the non-inferiority of
robotic surgery in oncological patients, including RCTs for bladder
cancer [8], rectal cancer [9], prostate cancer [10] or esophageal
cancer [11].
Due to the theoretical advantages of the robotic assisted sys-
tem, complex liver surgery might be an especially interesting indi-
cation for a robotic approach since it demands delicate tissue
dissection (e. g. dissection of the hepatic hilum and hepatocaval
plane or mobilization of the liver), precise intracorporeal suturing
(e. g. vascular reconstruction or biliary anastomosis) as well as
difficult parenchymal transection with subsequent need for meti-
culous hemostasis and biliostasis. This review will provide a gener-
al overview of the existing literature along with current standards
and aims to specifically point out future directions of robotic liver
surgery.
Becker F et al. Robotic Liver Surgery… Z Gastroenterol 2021; 59: 56–62 | © 2020. Thieme. All rights reserved.
Current standards
The standard approach in modern liver surgery should be a mini-
mal invasive one, complemented by hybrid and hand-assisted
strategies or open resections for highly complex cases. Benefits
of minimal invasive over conventional open liver surgery have
been well established [12, 13], including reduced intraoperative
blood loss, reduced postoperative pain, shorter length of stay
and lower risk for perioperative complications in combination
with a non-inferiority in oncological results. These advantages
are currently reflected by recommendations from the 2018
Southampton consensus guidelines for laparoscopic liver surgery,
stating a clear indication for minimal invasive approaches for cer-
tain resections (left lateral and anterior segments) [14]. This is
in accordance with the 2008 Louisville [15] and updated 2014
Morioka statement [16].
Is Robotic Surgery an Extension to Laparoscopy
or Alternative to Open Resection?
The pattern of establishing robotic liver surgery followed the trend
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of laparoscopic liver surgery, starting with benign (e. g. focal nodu-
lar hyperplasia, hemangioma, or hepatocellular adenoma) or
peripherally located lesions (left lateral section (II, III) or anterior he-
patic segments (IVb, V, VI)) with progression to more advanced
procedures including major hepatectomies and resections of pos-
tero-superior segments (IVa, VII, VIII). Although safety and feasibil-
ity of laparoscopic resections of the postero-superior segments as
well as major resections have been thoroughly established by spe-
cialist centers over the last decade, these procedures are still
conducted mainly as open resections in most peripheral centers.
Nguyen et al. conducted a review of 2804 laparoscopic liver resec-
tions and found that 65 % of laparoscopic hepatectomies involve a
non-anatomic resection or left lateral sectionectomy, while only
9 %, 7 %, and 1 % represent major anatomic right, major anatomic
left and extended hepatectomies, respectively [17]. These numbers
call into question as to whether these more complex patients
wouldn’t be the ones who profit the most from a minimal invasive
procedure, especially in terms of blood loss, post-operative recov-
ery, cosmesis, pain, and length of stay [18]. Therefore, especially
in complex cases including major hepatectomies, extended hepa-
tectomies with biliary reconstruction and difficult segmentectom-
ies of the posterior-superior segments, robotic surgery appears to
emerge as a reasonable alternative to open surgery rather than
being an alternative to laparoscopic procedures.
In line with this Guerra et al. [19] promoted the uses of robotic
surgery in resection of hepatic malignancies located in segment
VII. While normally conducted by conventional open procedures
with large thoracoabdominal or abdominal incisions [20], the ro-
botic platform overcomes technical limitations of laparoscopic
surgery but retains the advantages of minimal invasive surgery,
including reduced trauma to the abdominal wall and parenchy-
mal-sparing surgery [21]. Accordingly, Nota et al. [22] conducted
a multinational, multi-institutional propensity score-matched
study and reported superior short-term outcomes of robotic re-
sections of posterosuperior segments when compared to open
surgery. By further advancing the idea of specific patient selec-
57
 Übersicht
tion, Melstrom et al. developed a concept of selecting incision
dominant cases for robotic liver surgery: They chose resections in
poorly accessible locations, excluding a laparoscopic approach
and thus requiring large open incisions or cases in which the inci-
sion was suggested to dominate the course of recovery [23]. By
employing this concept, they achieved a 90 % robotic completion
rate and were able to discharge 66 % of all patients in less than
three days (including three hemi-hepatectomies), with fourteen
patients even being discharged at the day of surgery.
Short-Term Outcomes
Due to paucity of RCTs, most data are drawn from single center
case-cohort studies. The first large series was presented by Tsung
et al. in 2014 as a retrospective cohort study, matching 57
(36 minor, 21 major) robotic with 114 (72 minor, 42 major)
laparoscopic (total, hand-assist and hybrid approaches) hepatic
resections [18]. Parenchymal dissection was conducted by crush-
clamping techniques with clips and suturing for robotic resec-
tions, while linear staplers were used for laparoscopic liver resec-
tions. The authors found no significant differences in most opera-
tive (blood loss, transfusion rate), postoperative (postoperative
peak bilirubin, postoperative intensive care unit admission rate,
length of stay and 90-day mortality, postoperative complications)
as well as oncologic (R0 negative margin rate) outcomes. How-
ever, a significant longer overall room time and OR time was no-
ted in the robotic group. One interesting finding was that there
were only four conversions to an open procedure in the robotic
group (bleeding, difficulty in liver mobilization and inability to
access hilum), demonstrating that 93 % of all robotic cases were
done purely minimally invasive. On the contrary, only 49.1 % of
laparoscopic cases were conducted in a purely minimally invasive
manner, with 10 conversions, 31 hand-assist procedures and
16 hybrid operations. When compared to open major hepatec-
tomies, robotic surgery revealed a significantly reduced estimated
blood loss and shorter hospital stay. This highlights that robotic
surgery inherences the advantages of minimal invasive surgery
over conventional procedures but might allow to perform more
difficult and challenging procedures purely minimally invasive
when compared to laparoscopic surgery.
With the absence of RCTs, the currently highest level of evi-
dence concerning robotic liver surgery can be drawn from meta
analyses. Several meta-analyses have established that compared
with open hepatectomy robotic liver surgery is associated with
significantly lower complications, reduced blood loss and blood
transfusion rates along with shorter length of stay, while provid-
ing similar R0 resection rates as well as equal rates for 5-year over-
all and disease-free survival [13, 34–36].
It is notable that the pooled data from meta-analyses compar-
ing robotic with laparoscopic surgery are currently inconsistent.
Among the most recent meta-analysis is the work from Zhang
et al., combining data from 28 articles, involving 3544 patients
and comparing outcomes of robotic (1312 cases) with laparo-
scopic (2232 cases) liver resection. The authors could demon-
strate that robotic liver surgery was associated with a longer op-
erative time, higher transfusion rate (although estimated blood
loss was equal between the two groups) but lower conversion
58 Becker F et al. Robotic Liver Surgery… Z Gastroenterol 2021; 59: 56–62 | © 2020. Thieme. All rights reserved.
rate. When analyzing pooled data for postoperative outcome indi-
cators, no significant differences were found. Guan et al. analyzed
pooled data from 435 robotic and 503 laparoscopic cases and
found a significantly increased blood loss in the robotic cohort
[37]. This is in contrast to recent meta-analyses by Kamarajah
et al., including 2630 patients (950 robotic and 1680 laparoscopic
cases) undergoing liver resection, revealing a significantly re-
duced estimated blood loss with no differences in transfusion
rates between robotic and laparoscopic liver resection [31].
Among the possible explanations for the apparently conflicting
finding regarding intraoperative blood loss is the mixed popula-
tion of major and minor resections, with a trend to more extensive
resections in the robotic cohorts. When comparing only major
resection (removal of three or more Couinaud segments) be-
tween 300 laparoscopic and 225 robotic cases, a recent meta-
analysis by Ziogas et al. found no significant differences regarding
transfusion rate and estimated blood loss, along with of overall
equal rates for severe complication and overall mortality [38].
Therefore, it can be concluded that robotic and laparoscopic he-
patectomy are equivalent regarding the majority of outcomes of
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interest.
Enhanced Recovery. A Key Step in Reducing Cost
and Improving Oncological Outcomes
The aspect of postoperative recovery has been studied by Frus-
cione et al. in a cohort of major liver resections (57 robotic and
116 laparoscopic). Among the key findings in this study are a sig-
nificantly reduced postoperative intensive care unit admission and
90-day readmission rates in the robotic group [29]. This was fur-
ther supported by a report from Cortolillo et al. [30] using large
registry data from the Nationwide Readmission Database. Com-
pared to open (n = 10 146) and laparoscopic (n = 520) hepatect-
omy, robotic procedures (n = 204) were associated with a shorter
length of stay and less frequent non-elective readmission within
45 days. Same results were reported in two recent meta-analyses
by Kamarajah et al. as well as by Gavriilidis et al. revealing signifi-
cantly lower readmission rate for robotic compared with laparo-
scopic liver resections [13, 31]. All of this provide evidence of
favorable recovery in patients undergoing robotic liver resection
as evident by reduced complications, lower rates of intensive
care unit admissions, shorter length of stay and less frequent
non-elective readmissions. This is of special interest for patients
with hepatic malignancies, since postoperative complications
have been shown negatively affect long-term survival and recur-
rence, while prolonged recovery expands the time to initiation of
adjuvant chemotherapy, which has also negative effects on survi-
val [32, 33]. This further emphazise theoretical advantages of
robotic surgery in patients with hepatic malignancies.
Oncological Outcomes
Having established safety and feasibility of robotic liver resection,
oncological outcomes became a special area of interest. A large
European bi-institutional study compared outcomes of liver resec-
tions for hepato-biliary malignancies between 111 laparoscopic
with 61 robotic procedures in a propensity score matched study,
with data being retrieved from prospectively maintained files
[24]. The authors found no significant differences in operative
time, blood transfusion as well as 90-day overall morbidity. A spe-
cial focus of this study was oncological outcome, showing that R1
resection rate as well as mean surgical margin width were similar
in both groups. In addition, 1-, 2-, and 3-year overall survival rates
as well as 1-, 2-, and 3-year recurrence-free survival were similar
between the laparoscopic and robotic cohort. This study demon-
strates that the excellent oncological results obtained with laparo-
scopic surgery can be preserved when applying robotic surgery.
There are currently two larger series investigating oncological
outcomes in terms of resection margins, disease-free and overall
survival for robotic surgery in patients with hepatocellular carci-
noma. Chen et al. conducted a matched comparison between ro-
botic and open hepatectomies, with 81 patients in each group
being compared under propensity score matching [27]. Percen-
tage of major liver resections (41.9 for robotic vs. 39.5 % for
open surgery) and liver cirrhosis (45.7 for robotic vs. 46.9 % for
open surgery) was comparable between the two groups, respec-
tively. In addition, hepatitis profiles, preoperative liver function
tests, tumor size, cancer TNM stage, histology grade and tumor
localization were also similar. Surgical outcomes were comparable
except a significant longer operation time for robotic procedures.
However, the robotic group also showed a significantly reduced
shorter hospital stay (7.5 vs. 10.1 days), and lower dosages of pa-
tient-controlled analgesia. Concerning oncological results, 3-year
overall survival (92.67 for robotic vs. 93.7 % for open surgery)
showed no differences while 3-year disease-free survival of the
open group was markedly reduced (72.2 % for robotic vs. 58.0 for
open surgery) without reaching statistical significance (p = 0.062).
The largest series comparing long-term oncological outcomes of
robotic (n = 100) and laparoscopic (n = 35) hepatectomies for he-
patocellular carcinoma was published by Lai et al. [28]. Although
the robotic cohort had a significant higher proportion of major
hepatectomies (27 % vs. 2.9 %) and tumors located at or across
posterosuperior segments (29 % vs. 0 %), morbidity and mortality
were comparable. Regarding oncological outcomes, the study
showed similar results for R0 resection rates, 5-year overall survi-
val (65 % vs. 48 %), and disease-free survival (42 % vs. 38 %) be-
tween robotic and laparoscopic groups. All together these studies
demonstrate a non-inferiority of robotic liver surgery for hepato-
cellular carcinoma in terms of resection margins, disease-free and
overall survival, while providing evidence for an enhanced post-
operative patient recovery.
The issue of oncological outcomes was further addressed by an
international, multicenter, retrospective study of 61 patients un-
dergoing robotic liver surgery for hepatocellular carcinoma
(56 %), cholangiocarcinoma (26 %) or gallbladder cancer (18 %)
[25]. It was revealed 5-year overall- and disease-free survival
were 56 and 38 %, respectively, which is comparable to published
survival data for open and laparoscopic procedures. However,
subgroup analysis revealed inferior outcomes for patients with
extrahepatic cholangiocarcinoma undergoing robotic liver sur-
gery. This was also postulated by Xu et al. [26] analyzing oncolo-
gical outcomes of patients with hilar cholangiocarcinoma, of
which 10 (Bismuth–Corlette type II (n = 1), IIIa (n = 4), IIIb (n = 1)
and IV (n = 4)) underwent robotic and 32 conventional open sur-
gery. While these challenging robotic procedures (hemi-hepa-
Becker F et al. Robotic Liver Surgery… Z Gastroenterol 2021; 59: 56–62 | © 2020. Thieme. All rights reserved.
tectomy plus caudate lobectomy or trisectionectomy, extrahepa-
tic bile duct resection, radical lymphadenectomy and Roux-en-Y
hepaticojejunostomy) were technical feasible (no conversion oc-
curred), surprisingly the oncological outcome was inferior in the
robotic group, evident by a shorter recurrence-free survival time
(median 15.5, range 6–60 months, Log-rank p = 0.029). Why
these patients had an inferior oncological outcome remains
unclear but possible explanations can be hypothesized: At first,
patients in the robotic group showed a higher postoperative mor-
bidity, which is known to negatively correlate with the oncological
outcome. Then, a high rate of peritoneal metastasis/implantation
(40 % of patients) as well as multi-site metastasis (20 %) was nota-
ble, suggesting a possible implantation during surgery due to
instrumental manipulation or aerosols produced by power equip-
ped instruments. In addition, the robotic operations were con-
ducted between 2009 and 2012, being at the early phase of the
learning curve of the respective surgeons, which might have a rel-
evant impact, too. However, so far, these concerns were not
followed by subsequent studies and highlight the urgent need
for prospective, randomized data.
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Future perspectives
Robotic surgery is only in the beginning of its evolution. Purely
based on its digital nature, the robotic system will undoubtably
be at the center of future innovations in liver surgery. Technical
advances will be further fueled by completion as intellectual prop-
erty constraints are fading and new companies are entering the
market [39]. We can expect better systems for single-incision ro-
botic surgery, which can be combined with natural orifice speci-
men extraction [40]. In addition, advances in parenchymal dissec-
tion deceives such as a Cavitron Ultrasonic Surgical Aspirator
(CUSA) for the robotic platform are urgently awaited. But we are
also on the verge of a technical revolution, including upcoming of
leverage integrated sensors, “smart instruments”, big data and
deep-learning technologies [39]. As of today, the robotic platform
already allows for integration of new technologies, including
ultrasound instruments or indocyanine green imaging [41]. All of
this will be further developed into augmented reality, providing
the robotic surgeon with simultaneously displayed data and pa-
tient-specific anatomical virtual models, allowing patient and
case specific image-guided surgery [42]. Future robotic platforms
will provide more than technical refinements such as suppressing
tremor, they will become more than a surgical tool by advancing
torwards a learning, globally connected data-harvesting surgical
interface. As a second level (parallel to pure technical support in
a master-slave setup), robots will use algorithms based on biologi-
cal, technical and procedural data to offer intellectual support in
cyber-physical systems [39].
In parallel to technical advances, robotic surgery will be used
for more complex operation in the future. In line with this, there
are first reports about robotic associating liver partition and portal
vein ligation for staged hepatectomy with excellent results in
highly selected cases [43–45].
In the setting of liver transplantation, robotic surgery can be
theoretically applied to live donor organ retrieval as well as the re-
59
 Übersicht
cipient operation. While living adult-to-adult as well as adult‐to‐
pediatric liver transplantation are both considered a valuable
approach to overcome organ shortage, the donor procedure
demands the highest level of safety but at the time aims to main-
tain the donor’s quality of life. These two principal goals have
driven the development of laparoscopic procedures and have
encouraged the implication of robotic surgery to further reduce
procedure associated mortality and morbidity in the donor. The
first reported case of a robotic live donor right hepatectomy was
presented in 2012 by Giulianotti et al. followed a subsequent case
series, providing first evidence regarding feasibility and safety [46,
47]. In 2020 Rho et al. [48] reported short-term outcomes from a
large Korean cohort study comparing robotic living donor right
hepatectomy with laparoscopy-assisted and conventional open
donor right hepatectomy. While no differences were noted for
postoperative complications, the robotic approach resulted in
less blood loss and lower postoperative pain scores compared
with the open procedure as well as better donor satisfaction with
cosmetic results and body image when compared with the laparo-
scopic procedure. These results were confirmed by Broering et al.
in a series 263 consecutive adult patients undergoing right lobe
living donor hepatectomy, of which 35 robotic and 70 open pro-
cedures were included in a propensity score matched analysis
[49]. The safety (no conversion, all grafts successfully transplan-
ted) was demonstrated and it was revealed that the robotic ap-
proach was associated with equally low complications, reduced
blood loss, diminished uses of patient-controlled analgesia and a
shorter hospital stay. Since robotic right lobe living donor hepa-
tectomy is undoubtably among the most complex resections, it
is of special interest that the authors noted a significant improve-
ment in operative time, which provides evidence for a successful
learning curve in the 35 cases. While these reports ensure the
safety and feasibility of robotic live donor organ retrieval, it is
important to note that there are currently no reports of robotic
liver transplantation in the recipient, indicating that robotic sur-
gery is only at its beginning in the field of liver transplantation
while major obstacles are still ahead.
Conclusion
Robotic surgery is the future of liver surgery. In comparison to
conventional open or laparoscopic surgery, the robotic platform
has the unique ability to progress exponentially due to its inherent
advantage of being a modern computer-based machine. This will
provide an undoubted advantage during the ever faster develop-
ing digital revolution.
We are only seeing the dawn of robotic technology. The vast
majority of the currently published studies was conducted during
the last decade and within this time alone robotic surgery has
experienced tremendous progress, including launch of new sys-
tems (da Vinci Xi in 2014)) or development of new dissection
devices. When compared to laparoscopy, robotic liver surgery
will allow to conduct more complex resections and to complete
more procedures purely minimal invasive. In addition, there is
robust evidence for a less steeper learning curve for robotic liver
60 Becker F et al. Robotic Liver Surgery… Z Gastroenterol 2021; 59: 56–62 | © 2020. Thieme. All rights reserved.
surgery compared to laparoscopic surgery (even for highly com-
plex cases), which will have a great impact on future results. This
will also be a factor when considering the two currently largest
disadvantages of robotic surgery, cost and operation time.
Numerous studies now demonstrated a reduced overall cost due
to shorter ICU stay, shorter hospital and reduced readmissions.
It is now thoroughly established that robotic liver surgery is
safe and feasible compared to open and laparoscopic surgery,
with at least non-inferior oncological outcomes. It will be among
the great challenges for the current and upcoming generation of
robotic liver surgeons to identify patients who profit the most
from this technology, while at the same time accept and maybe
overcome current limitations in extended oncological resections.
However, the authors strongly believe that equal R0 rates and
identical lymph node rates in combination with parenchymal
sparing resection, reduced blood loss, reduced trauma and
enhanced recovery will translate into superior oncological results
in future trials evaluating robotic liver surgery.
Conflict of Interest
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The authors declare that they have no conflict of interest.
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