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Page 2 of 7 Ruff et al. Mini-invasive Surg 2024;8:12 https://dx.doi.org/10.20517/2574-1225.2024.39

been slower given the complexity and elevated morbidity and mortality associated with these operations.
The first laparoscopic partial hepatectomy was performed in 1992 and demonstrated its safety for small
[1]
tumors in the left lateral segment . Since then, the use of laparoscopy for hepatectomies has steadily
[2]
increased . Compared to open surgery, laparoscopic hepatectomy is associated with decreased
complications, lower estimated blood loss (EBL), decreased time to return of bowel function, and decreased
[2-4]
length of stay . Equally as important, these studies showed that there are no differences in oncologic
outcomes between laparoscopic and open surgery .
[5-8]
However, there are some technical disadvantages with laparoscopy, especially for complex liver operations
that require hilar dissection or access to tumors in difficult anatomic areas (e.g., superior-posterior tumors).
Unlike laparoscopy, the robotic system provides a three-dimensional view and instruments with articulation
that mimic and extend wrist movement. These elements improve operative dexterity, making dissection and
suturing easier. Additionally, robotic surgery improves operative ergonomics and decreases physical and
[9]
mental fatigue . Studies show that similar to laparoscopy, robotic hepatectomies have improved short-term
post-operative outcomes over open surgery [10-12] . Furthermore, robotic liver surgery has a lower rate of
conversion to open procedures than laparoscopy [13-17] . As such, hepatobiliary surgeons are beginning to
utilize robotic techniques in their practice.

A study using the National Surgical Quality Improvement Program (NSQIP) database from 2014-2020
[18]
showed that 12% of the minimally invasive hepatectomies were performed robotically . While the number
of robotic hepatectomies is still relatively low, the robotic approach and the number of hospitals performing
robotic hepatectomies are on the rise in the United States . It is our duty as clinicians to ensure that as
[19]
more hospitals adopt this technology, patient safety and quality initiatives are maintained. Establishing a
robotic liver surgery program revolves around three pillars: designing a curriculum to overcome the
learning curve, building a strong clinical and administrative team, and appropriate patient selection.

DESIGNING A CURRICULUM AND OVERCOMING THE LEARNING CURVE
It is well established that for any new technology, there is an associated learning curve. Therefore, the
success of a new robotic program is contingent on a curriculum that ensures proficiency, and maintains
patient safety standards. Studies vary on the ideal number of cases required to overcome this learning curve
for robotic liver surgery, with some suggesting it can be as few as 20-30 cases [20,21] . However, Krenzien et al.
found that after adjusting for the complexity of the hepatectomy, the learning curve for robotic liver
[22]
resection was higher than previously reported . The discrepancy in the number of cases required to
overcome the learning curve may be due to multiple factors, including surgeon experience, difficulty of the
case, and participation in a training program. A single institution in Denmark reviewed its first 100 patients
to undergo robotic liver surgery and showed that standardization of training led to increased proficiency
and lower complication rates . Rather than establishing a required number of cases for proficiency, they
[21]
defined three phases of the learning curve: (1) the initial experience with simpler cases to establish a baseline
skillset; (2) the second stage that pushes the surgeon’s abilities with increasingly difficult cases; and (3) the
final stage where the surgeon demonstrates proficiency and more nuanced moves through additional
experience. With this in mind, studies have focused on curriculums designed to shorten the learning curve.

In the robotic pancreaticoduodenectomy (PD) literature, the University of Pittsburgh Medical Center found
the institutional learning curve for robotic versus open PD to be similar . While implementing their
[23]
robotic program for PD, they monitored outcomes in groups of 20 patients to ensure that safety and quality
were maintained. Furthermore, they established a five-step proficiency-based robotic training curriculum
that included a simulation component consisting of 24 virtual reality modules, practice sessions with