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Page 6 of 9 Nota et al. Mini-invasive Surg 2020;4:74 I http://dx.doi.org/10.20517/2574-1225.2020.57

Table 3. Postoperative outcomes
Parameter Outcome
Major complication, n (%) 10 (14)
Clavien-Dindo grade III a/b 7 (10)
Non-bilious fluid collection, drained radiologically 2 (3)
Non-bilious fluid collection, drained laparoscopically 1 (1)
Herniated omentum, closed under local anesthesia 1 (1)
Bilious fluid collection, drained radiologically 2 (3)
Trocar herniation, corrected surgically 1 (1)
Clavien-Dindo grade IV a/b 2 (3)
ICU admission for respiratory insufficiency 2 (3)
Bile leakage, n (%) 3 (4)
Grade A 1 (1)
Grade B 2 (3)
ICU admission, n (%) 5 (7)
Unplanned ICU admission, n (%) 3 (4)
Relaparotomies, n (%) 0 (0)
Minimally invasive drainages, n (%) 5 (7)
Length of stay, median (IQR), days 4 (3-6)
Readmission within 10 days, n (%) 4 (6)
Readmission within 90 days, n (%) 6 (9)
30-day mortality, n (%) 1 (1)
90-day mortality, n (%) 1 (1)
Trocar herniation within one year after surgery requiring surgical intervention, n (%) 2 (3)
ICU: intensive care unit; IQR: interquartile range

One patient died postoperatively due to post hepatectomy liver failure. The patient had a past medical
history of hepatitis B, no signs of cirrhosis or portal hypertension in preoperative hepatology evaluation,
and underwent right hepatectomy for a hepatocellular carcinoma. Due to the lack of anatomical overview
during parenchymal transection, the procedure was converted to open hemihepatectomy. Postoperatively,
the patient suffered from grade C posthepatectomy liver failure progressing to multiple organ failure and
death on postoperative day 12. Definitive pathology showed a hepatocellular carcinoma as well as liver
cirrhosis.

Comparison to conventional laparoscopy
A summary of several outcomes from our series and an overview of the outcomes of all laparoscopic liver
resections performed in the Netherlands between 2011 and 2016 are provided in Table 4. In total, 885
conventional laparoscopic liver resections were performed, of which 683 (77%) were minor resections.
Mean operative time was 164 min (SD 95) for the conventional laparoscopic liver resections and median
blood loss was 200 mL (IQR 50-500). A total of 121 procedures (14%) were converted to laparotomy and 76
patients (9%) suffered from a major complication. Nine patients (1%) died after conventional laparoscopic
liver resection. Outcomes of our robotic liver resections are comparable to the outcomes of all conventional
laparoscopic liver resections performed between 2011 and 2016 in the Netherlands.

DISCUSSION
In this study we report the surgical details and clinical outcomes of 70 consecutive robotic liver resections
in which the Vessel Sealer was used for parenchymal transection. Our results demonstrate that the use of
this device facilitates safe transection of the hepatic parenchyma, without compromising postoperative
clinical outcomes. No postoperative bleeding occurred and only three patients (4%) suffered from bile
leakage postoperatively.

Over the past decade, robotic surgery has become an important alternative to conventional laparoscopy.
Recently, a nationwide trend in the US towards an increase of the use of robotic surgery has been observed