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Zhang et al. Hepatoma Res 2020;6:77 I http://dx.doi.org/10.20517/2394-5079.2020.74 Page 3 of 7

industry still maintains a cautious attitude towards the transition to laparotomy because intraoperative
bleeding is difficult to effectively control for the safe integration of laparoscopic large-scale hepatectomy
or postoperative bleeding. Recent evidence from some centers has shown that laparoscopic hepatectomy
is acceptable for HCC patients who meet the surgical criteria, and there is no significant difference in
[31]
postoperative survival time [29,30] . Rao et al. compared 700 patients who underwent pure laparoscopic liver
resection and laparotomy. Compared with laparotomy, the overall incidence of complications after LH was
lower and the length of stay was shorter. For liver cancer patients with obvious liver cirrhosis, the studies
[32]
from Memeo et al. showed that, compared with laparotomy, patients who underwent laparoscopic
liver resection had shorter operation times and complete surgical margins, but there was no significant
difference in overall survival rate and disease-free survival time. The 1-, 5-, and 10-year survival rate of
laparoscopic liver resection (LLR) group reached 88%, 59%, and 12%, and that of open liver resection (OLR)
group was 63%, 44%, and 22%, respectively (P = 0.27). However, there is no evidence that patients with liver
cancer who undergo laparoscopic liver resection are afforded a better prognosis. In a recent study, Ahmed
[33]
El-Gendi et al. compared the therapeutic effects of OLR with LLR in patients with liver cirrhosis (Child A)
with solitary small (< 5 cm) peripheral HCC. The results showed that LLR had significantly less operative
time (120.32 ± 21.58 min vs. 146.80 ± 16.59 min, P < 0.001) and shorter duration of hospital stay (2.40 ±
0.58 days vs. 4.28 ± 0.79 days, P < 0.001), with comparable overall complications (25% vs. 28%, P = 0.02).
LLR had comparative resection time (66.56 ± 23.80 min vs. 59.56 ± 14.74 min, P = 0.218), amount of blood
loss (250 mL vs. 230 mL, P = 0.915), transfusion rate (P = 1.00), and R0 resection rate when compared with
OLR. There was no significant difference between the two groups in terms of postoperative tumor-free
[33]
survival time . In a Japanese study, information on patients undergoing liver cancer surgery was collected
from 31 centers between 2000 and 2010, and divided into LLR (n = 436) and OLR (n = 2969) groups.
387 patients were matched by propensity score matching. There were no significant differences in overall
survival and disease‐free survival between LLR and OLR. Patients undergoing LLR have shorter hospital
[34]
stays (13 days vs. 16 days, P < 0.001) and fewer postoperative complications (6.7% vs. 13.0%, P = 0.003) .

ROBOTIC LIVER RESECTION
With the progress and development of technology, the surgical treatment of liver cancer has gradually
entered the era of minimally invasive precision treatment, mainly including laparoscopic and robotic
minimally invasive treatment. The development of minimally invasive surgical techniques for liver
tumors is limited by the characteristics of its own organs, a crisp texture, abundant blood supply, high
numbers of structural variations of blood vessels and bile ducts, and a close relationship with surrounding
organs. Although laparoscopic liver resection has made great progress on the basis of the improvement
of laparotomy, it is easy to cause clamping or traction bleeding when the deep lesions and special liver
segments are exposed. Therefore, the control of intraoperative bleeding, the exposure of the operative
visual field and the effective hemostasis of liver section are the key points of minimally invasive surgery,
and also the biggest problem of laparoscopic liver resection [35,36] . In this case, the robot assisted system is
gradually improved. In 2000, Da Vinci robot assisted surgery system was approved for clinical use. It is one
of the most mature surgical auxiliary operating systems, which is widely used in the field of surgery. With
its unique advantages, it gradually fills the gap in the minimally invasive field of liver tumor treatment.
Traditional laparoscopic liver resection has some problems, such as inflexible fixation of the operating
instruments and a large swing of the visual field leverage effect [37,38] . The robot assisted surgery system has
no such limitations, and the highly bionic operation can greatly simulate the fine operation of the open
hand, provide stable, fixed strength and angle traction and exposure, and even surpass the human operation
[39]
[40]
to a certain extent , and complete the accurate resection and suturing of malignant liver tumors . In
[38]
2003, Giulianotti et al. {Giulianotti, 2003 #170} reported the first robotic liver resection in the world.
Under this background, robotic surgery technology has been developing rapidly. At present, the Da Vinci
surgical assistant system is widely used in various benign and malignant liver diseases, including for the
indications of laparoscopic hepatectomy . For some special liver segment tumors, robot assisted surgery
[41]