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Page 2 of 15 Ruzzenente et al. Mini-invasive Surg 2020;4:91 I http://dx.doi.org/10.20517/2574-1225.2020.90

Keywords: Robotic liver surgery, robotic liver resections, laparoscopic liver resections, hepatocellular carcinoma,
cholangiocarcinoma, gallbladder cancer, colorectal liver metastases

INTRODUCTION
Since its introduction, robotic surgery (RS) has received great interest from scientific societies. In the era of
minimally invasive surgery (MIS) it represents an advanced technique able to overcome some limitations
of laparoscopy. Nevertheless, its use is not standardized in hepatobiliary surgery. Although single surgeons
and centers have published their experiences demonstrating the safety and feasibility of the technique, large
international studies are limited and few publications reported long-term outcomes. The advantages of RS
are several: it provides increased surgical dexterity and enhanced suturing ability, thanks to a magnified
three-dimensional view of the operative field, hand tremor filtration and articulating instruments with
seven-degrees of freedom. Furthermore, this approach reduces significantly surgeons’ fatigue, improving
[1,2]
performances for long operations . In addition, RS supports and upgrades the technology of specific
surgical tools, that can help surgeons to face challenging situations and improve surgical results, such as
with intraoperative ultrasound, near-infrared fluorescence with indocyanine green, CT and MR images
integrated into the robotic console. The images can be simultaneously displayed with the operative field
during liver parenchymal transection, allowing the surgeon to change the previously marked transection
line if necessary and to detect further lesions, gaining adequate margins for malignancies [3-5] . On the
contrary, current RS systems’ disadvantages include the absence of a dedicated instrument for transection
(i.e., CUSA), the need for additional surgeons and time for instrument replacement, the learning curve of
[2]
the team to dock the instruments and the lack of haptic feedback . Nonetheless, the development of skills
and experience of the surgical team can significantly decrease the length of RS associated to the docking
[6]
time and the replacement of the instruments . Finally, one of the major drawbacks of RS are costs, limiting
its use to selected surgical procedures and few centers. As a minimally invasive approach, RS allows
improvement of almost all the parameters of postoperative recovery, such as pain control, oral intake, post-
operative morbidity and length of hospital stay . Recently, the Southampton international guidelines,
[7]
providing indications and limits of liver MIS, advocated RS as a promising, but not yet standardized,
approach . The aim of this review was to analyze the results of robotic hepatobiliary surgery and to
[8]
compare them with laparoscopy, in order to clarify the benefits and contraindications of RS.

METHODS
A search of the current literature on robotic liver surgery was conducted in PubMed, Medline, PMC
and Google Scholar databases. The research terms adopted were: robotic/robot-assisted liver surgery/
resection, hepatic robotic surgery/resection, robotic/robot-assisted hepatectomies. Only articles published
in English were selected. Further reports were retrieved from those listed in the articles’ references and
from the manual search on specific additional topics, such as robotic surgery for hepatocellular carcinoma,
cholangiocarcinoma, gallbladder cancer, colorectal liver metastases, lesions located in postero-superior
liver segments, comparison between laparoscopic and robotic hepatic resections.

Among the 112 publications analyzed, the most significant were selected according to the following
factors: quality of data reported and of statistical analysis adopted, relevance in scientific literature,
date of publication. In case of overlapping studies with the same first author, the most recent was
chosen. Once reviews, meta-analyses and studies reporting incomplete or unclear information were
excluded, the following data were extracted from the 72 remaining publications: patient characteristics
(number of patients, age, sex, body mass index, ASA score, comorbidities, previous chemotherapy
and abdominal surgery), operative procedure (type of resection, use of Pringle maneuver, additional
simultaneous procedures, intraoperative drain placement, estimated blood loss, operation time,