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Ruzzenente et al. Mini-invasive Surg 2020;4:91 I http://dx.doi.org/10.20517/2574-1225.2020.90 Page 3 of 15

Figure 1. Selection of articles

conversion rate), histopathology (nature of the lesion, median tumor size, number of lesions, margin
status, lymphadenectomy), short-term outcomes (overall morbidity, major complications, perioperative
blood transfusions, admission to intensive care units, length of hospital stay, surgery-related readmission,
reoperation within 30 days, 30- and 90-days mortality), long-term outcomes (disease free survival, overall
survival), costs [Figure 1].

Minor and major resections were defined according to the Brisbane 2000 Terminology of Liver Anatomy
[9]
and Resections . The Clavien-Dindo Classification of surgical complications was adopted to define major
[10]
complications as grade three or more . Firstly, 29 publications on robotic liver surgery were selected and
reviewed, excluding those reporting less than 20 patients. Secondly, 25 articles comparing robotic and
laparoscopic liver resections were reviewed. Eventually, 4 sub-group analyses were conducted including
studies on single malignant hepatobiliary diseases: hepatocellular carcinoma (HCC), gallbladder cancer
(GBC), hilar cholangiocarcinoma (hCCC), colorectal liver metastases (CRLM).

RESULTS
Robotic liver surgery
Twenty-nine articles, published in the last five years (2015-2020) including a number of patients greater
than or equal to 20, were analyzed [Table 1]. The total number of patients reported in 29 studies was 1831,
with a median number of 61 patients (range 20-183). The median age was 61 years old (range 45-69.4). All
the studies were retrospective and most of them reported cumulative results, without any differentiation
between benign and malignant diseases or minor and major liver resections.

Type of liver resection
Referring to the type of resections, 1328 (69.5%) were minor, and 584 (30.5%) were major resections. The
[8]
number of “technically major resections” (segments 1, 4a, 7, 8) collected was 214 (11.7%). The studies
including resections of these segments reported a longer operative time and greater estimated blood loss
[11]
(EBL). Nota et al. published a multi-institutional propensity score study (31 matchings), demonstrating
that minor robotic resections of postero-superior segments were safe and feasible, improving outcomes
in comparison with open surgery [median EBL 180 mL vs. 300 mL, operative time 198 min vs. 255 min,
length of stay (LOS) 4 days vs. 10 days].