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Page 2 of 6 Labadie et al. Hepatoma Res 2020;6:65 I http://dx.doi.org/10.20517/2394-5079.2020.86

3-dimensional high definition optics, improved surgeon ergonomics, diminished surgeon fatigue, as well
as a shortened learning curve compared to standard laparoscopic liver surgery. Several disadvantages are
emphasized by detractors of the robotic technique, including the need for experienced teams, substantial
acquisition and operational costs, and concerns over lack of benefit over standard laparoscopic surgery [12,13] .

[14]
Robot-assisted laparoscopic liver resection (RALLR) was first described in the 2000s , with the initial
[15]
landmark case series of 70 patients reported by Guilianotti and colleagues in 2010 . The indications
for RALLR mirror those of the standard laparoscopic approach, including resection of both benign and
malignant tumours in patients who can tolerate general anaesthesia and prolonged pneumoperitoneum.
Over the last two decades, numerous single and multi-institutional case series have reported outcomes of
RALLR in high-volume centres, demonstrating it to be safe, feasible, and effective for minor and major
hepatectomies . Compared to standard laparoscopic liver resection, perioperative outcomes including
[16]
operative time and estimated intraoperative blood loss have been shown to be higher in RALLR, but the
open conversion rate, R0 resection rate, hospital length of stay, morbidity and mortality are no different
[17]
than standard laparoscopic hepatectomy . Indeed, RALLR recapitulates the main benefits observed with
standard laparoscopic hepatectomy in comparison to open hepatectomy, including reduced postoperative
complications and shorter length of stay without compromising oncological outcomes such as radical
resection rate, overall survival, and disease-free survival rate [18,19] . The accumulation of evidence supporting
RALLR resulted in international consensus guidelines promoting the development and standardization of
robot-assisted laparoscopic hepatectomy in 2018 .
[20]
RALLR is indicated for resection of all liver tumour types including hepatocellular carcinoma (HCC). It
has been demonstrated to be safely performed for patients with HCC who have well-compensated cirrhosis
without signs of severe portal hypertension. Evidence examining the safety and oncological effectiveness of
RALLR for HCC is accumulating, with a systematic review published in 2018 highlighting the favourable
[21]
short-term outcomes reported in over 300 patients from 10 institutional series . In the largest series
[22]
examining RALLR for HCC to date, Chen et al. performed a propensity score matching analysis of 81
RALLR and 81 open liver resections for HCC. In this report, which included approximately 40% major
hepatectomies, operative time was longer in the RALLR compared to open cohort (median of 343 min vs.
220 min). However, the intraoperative blood loss (median 282 mL vs. 263 mL), percent of patients requiring
an intra-operative blood transfusion (7.4% vs. 3.7%), and postoperative complications (4.9% vs. 3.7%) were
comparable between the two techniques. Notably, the authors observed a significantly reduced length of
hospital stay (median 7.5 days vs. 10.1 days), reduced patient-controlled analgesia use on postoperative day
1 and during initial ambulation in the RALLR compared to open hepatectomy cohort. Similar outcomes
have been observed in other institutional cohorts; however, it is worth noting that these early published
series come from high-volume institutions with extensive experience with laparoscopic liver resection,
potentially limiting the generalizability of these findings.

Given the relatively recent adoption of RALLR, studies examining the long-term oncological outcomes in
patients after resection for HCC are limited. An early and available outcome that many authors examine as
a surrogate for oncological efficacy is the R0 resection rate, as a positive histological margin is known to be
[23]
associated with a higher incidence of postoperative recurrence in HCC . R0 resection rate may also serve
as a hallmark of technical feasibility, as lower R0 resection may indicate suboptimal technical skill or an
inherent limitation of the technology (i.e., inability to palpate tumour with minimally invasive approach).
[16]
Published RALLR R0 resection rates are high, ranging from 85%-100% in most series . In regard to long-
term oncological outcome data, four of the largest studies examining RALLR for HCC report disease-free
survival and overall survival ranging from 72% to 75% and 93% to 98% at 2 and 3 years postoperatively,
respectively [24-26] . These mid-term oncological data are encouraging, but will need confirmation with longer-
term outcome reporting.