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Page 4 of 7 Zhang et al. Hepatoma Res 2020;6:77 I http://dx.doi.org/10.20517/2394-5079.2020.74

is more advantageous. Traditionally, it has been considered that if the tumor located in a location difficult
to dissect, intraoperative hemorrhage is anticipated to be difficult to control, or the tumor is large, these are
relative contraindications to the use of minimally invasive surgery. The advantages of robot assisted surgery
system can solve these problems, and the operation position is no longer the taboo of minimally invasive
surgery. For tumors in the upper right posterior lobe or caudate lobe of the liver, robot assisted surgery
[37]
has a better visual field than laparoscopic liver resection, and the process is more smooth [42,43] . Hu et al.
performed a meta-analysis of 17 case-control studies with different surgical methods, including 487
robotic cases and 902 laparoscopic cases. The results showed that the amount of blood loss in robotic
liver resection was significantly increased and the operation time was significantly longer than that in
traditional laparoscopic surgery, and there was no significant difference in blood transfusion volume and
blood transfusion rate between 33 cases with robotic surgery and 25 cases with laparoscopic liver resection.
There was no significant difference in hospital stay, conversion rate to laparotomy, R0 resection rate,
[44]
complications, or mortality between the two groups. Zhao et al. reported that successful robotic radical
resection of hepatic echinococcosis located in posterosuperior liver segments, and robotic isolated partial
[46]
[45]
and complete hepatic caudate lobectomy . In addition, Hu et al. indicated that robotic and laparoscopic
hemi-hepatectomies were associated with less intraoperative blood loss, better postoperative recovery
and a lower pain score. Compared with laparoscopic hemi-hepatectomy, robotic hemi-hepatectomy
was associated with significantly less intraoperative blood loss and a shorter operative time. In terms
of economic benefits, the medical cost of laparoscopic hepatectomy was relatively lower. There was no
significant difference in 5-year overall survival rate and disease-free survival rate between the two groups
(65% vs. 48%, 42% vs. 38%). Therefore, the high cost of treatment, the high requirements of operation
technology and the difficulty in popularizing technical equipment may be the biggest shortcomings in the
development of robotic surgery.

CONCLUSION
We have presented a comparison of published evidence for open, laparoscopic, and robotic liver resection,
including systematic review and meta-analysis evidence summarizing the advantages and disadvantages
of the three techniques, One of the analyses included 26 studies, including 2,630 patients (950 robotic
laparoscopic surgery and 1,680 laparoscopic patients). The amount of bleeding in patients undergoing
robotic hepatectomy was significantly reduced (286 mL vs. 301 mL, P < 0.001). There is no significant
difference in postoperative complications of the various surgical methods. However, there is one thing
worthy of our attention that patients undergoing robotic liver resection have a higher readmission rates
(P = 0.005), Compared with traditional open surgery, minimally invasive surgery (robot and laparoscopic)
is more expensive, but there is no statistical difference. It can significantly reduce intraoperative blood
loss and shorten the length of stay; the tumor volume of patients undergoing laparoscopic liver resection
was significantly reduced than patients in the open surgery group [47-49] . Minimally invasive surgery for
HCC is not a simple minimally invasive technology, but a process of minimally invasive concept and
comprehensive treatment. For example, the ALPPS procedure (associating liver partition and portal
[50]
vein ligation for staged hepatectomy) was proposed by Schnitzbauer et al. in 2015. In order to obtain
sufficient liver function reserve, create conditions for surgery, and solve the problem of insufficient residual
liver volume, it is necessary to make the impossible possible. However, because of its higher rate of
complications, the mortality rate is as high as 12%, and, therefore, this kind of operation has caused great
controversy. Currently, there is no clear clinical data to support its effect, as well as many postoperative
complications, which cannot be popularized in clinical practice. Other studies have shown that the
recurrence rate of ALPPS is increased . Moreover, the key objective of ALPPS is to block the blood supply
[51]
of the tumor, promote the growth of residual liver, and avoid postoperative liver failure. However, PVE can
play a similar role in clinical practice. At present, there is no clinical evidence to prove the overall prognosis
of ALPPS. With the development of technology and the improvement of surgical techniques, patients will
increasingly benefit from minimally invasive surgical precision treatments for liver pathologies.