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Page 6 of 11 Ziogas et al. Mini-invasive Surg 2020;4:69 I http://dx.doi.org/10.20517/2574-1225.2020.63

hepatobiliary surgeons . A Korean group recently published the initial experience of a single surgeon
[42]
with robotic liver surgery and showed that there was no difference in operating time between robotic and
laparoscopic left hepatectomy (248.6 ± 37.5 min vs. 226.7 ± 26.6 min) . Another recent study comparing
[45]
robotic vs. laparoscopic right hepatectomy demonstrated that operating time was significantly shorter in the
robotic group compared to the laparoscopic one (425 ± 139 min vs. 565.18 ± 183.73 min), and all procedures
were performed by the same young surgeon . That may serve as an indicator that as experience with
[40]
RMH grows, operating time seems to decrease and to be equivalent to, or even shorter than, that of LMH.
However, a major confounding factor is surgeon’s surgical expertise and prior experience with minimally-
invasive major hepatectomy; thus, future studies comparing operating time, as well as other parameters,
between RMH and LMH should always mention primary surgeon’s prior experience and should make sure
that the two comparison groups are equivalent regarding this parameter.

ESTIMATED BLOOD LOSS
The pooled estimated blood loss (EBL) in RMH based on two systematic reviews was 543.4 ± 371 mL and
[114]
380 ± 505 mL , respectively. The pooled mean EBL for the LMH arm in a systematic review comparing
[18]
LMH to open major hepatectomy was 450.6 ± 563.2 , which is comparable to the pooled rates reported
[116]
in the RMH systematic reviews [18,114] . However, major deviations were found between the individual RMH
or LMH studies themselves included in each systematic review. Cipriani et al. reported a median EBL of
[109]
350 mL (IQR 125-1350) for LMH, and more specifically 400 mL (IQR 200-800) for right hepatectomy and
300 mL (IQR 50-260) for left hepatectomy. Studies directly comparing EBL between RMH and LMH showed
that EBL in RMH was lower than that in LMH, while the difference was not statistically significant in any
of the individual studies [20,40,42,94] .

LENGTH OF STAY
Two prior systematic reviews on RMH reported a pooled mean hospital length of stay (LOS) of 10.5 ± 4.8
[114]
and 11 ± 6 days , respectively. The mean LOS of most individual studies included in a systematic review
[18]
on LMH was shorter than that of the two RMH systematic reviews. Another systematic review showed
[115]
that the pooled mean LOS for LMH was 10 ± 8.7 days . Cipriani et al. reported a median LOS of 6 days
[116]
[109]
(IQR 4-10) for LMH, and more specifically 7 days (IQR 4-13) for right hepatectomy, and 5 days (IQR 4-10)
for left hepatectomy. Studies reporting on the direct comparison of RMH vs. LMH did not demonstrate any
statistically significant difference between the two arms [20,40,42,94] .

COMPLICATIONS, SURVIVAL AND ONCOLOGIC OUTCOMES
When comparing RMH and LMH, Tsung et al. reported that no difference was observed between the two
[20]
groups with a complication rate of 24% (n = 5/21) vs. 32% (n = 13/42), respectively, while only one patient in the
RMH group experienced a major complication (Clavien-Dindo grade ≥ 3) (4.8% vs. 0%, respectively). The 90-day
mortality rate was 0% in both groups . Similar complication rates were documented by Spampinato et al.
[20]
[94]
RMH: 20% (n = 5/25) vs. LMH: 36% (n = 9/25), with 4% (n = 1/25) and 12% (n = 3/25) of the patients
experiencing a major complication (Clavien-Dindo grade ≥ 3), respectively. However, one patient in the
LMH group died . Marino et al. also failed to show a difference in morbidity with 21.4% (n = 3/14) of
[40]
[94]
the patients in the RMH arm vs. 15% (n = 3/20) in the LMH group experiencing any complications, while
no major complications occurred. Ninety-day mortality was 0% in both groups . The largest and most
[40]
recent comparative study between RMH and LMH was performed by Fruscione et al. and also did not
[42]
show a significant difference in complications between the two groups. Specifically, the complication rate
for RMH was 28.1% (n = 16/57) and for LMH 35.3% (n = 41/116), with 7% (n = 4/57) and 9.5% (n = 11/116)
being classified as major complications (Clavien-Dindo grade ≥ 3). No death was reported in either of the
comparison arms . Additionally, when RMH and LMH were performed for liver malignancies, none of the
[42]
four studies showed a difference in surgical margin status between the two approaches (positive margins:
0%-8.3% vs. 7%-15%, respectively), and long-term outcomes were comparable when reported [20,40,42,94] .