Page 69 - Read Online

Ruzzenente et al. Mini-invasive Surg 2020;4:91 I http://dx.doi.org/10.20517/2574-1225.2020.90 Page 5 of 15

Conversion to open surgery occurred with a median of 5.45% (range 0-14.8). Four authors reported
that higher conversions rates (greater than 10%) were related to bleeding, adhesions, technical difficulty,
advanced oncological diseases and the requirement of adequate oncologic margins [2,18-20] .

Histopathology
Among the indications for RS of the 29 articles reviewed, malignancies were the 84% of the cases, in
particular the most frequent indication was HCC (40%), followed by CRLM (21%), other metastases (14%),
cholangiocarcinoma (CCC) (9%), GBC (3%) and other malignancies (13%). The median tumor size was 33 mm
[21]
(range 17.8-73). Efanov et al. emphasized that resections of greater tumors (up to 73 mm) should be
performed by RS at the end of the surgeon’s learning process. The median rate of R0 margin status was
95.5% (range 72.9-100).

[20]
Interestingly, Khan et al. published an international multicenter study, in which they stratified their
results for RS by tumor type (3-years overall survival was 90% for HCC, 65% for GBC and 49% for CCC)
and reached comparable long-term outcomes, such as overall survival (OS) and disease free survival (DFS),
to those of open and laparoscopic liver resections available in literature.

In conclusion, despite the lack of long-term results available in literature, RS is considered feasible and
effective in the treatment of malignant diseases.

Short-term postoperative outcomes
ICU admission rate was described in 6 studies reporting a median frequency of 27.9% of patients requiring
[12]
ICU postoperative care (range 0-83.8). Daskalaki et al. , even if reporting the 83.8% of ICU admission
after RS, described a reduction in the length of the ICU stay in comparison with open surgery (2.1 days vs.
3.3 days, respectively).

The median rate of overall complications of the 29 reports reviewed was 18.5% (range 1.7-68.2), with a
[22]
median rate of major complications (Clavien-Dindo grade 3 or greater) of 4.7% (range 0-25). Choi et al.
reported a greater frequency of overall and major complications in minor resections compared to major
[12]
hepatectomies (46.7% vs. 42.6% and 13.3% vs. 9.3%, respectively), otherwise Daskalaki et al. described
a major rate of overall and major complications in major resections (31% vs. 15.3% and 6.8% vs. 2.5%,
respectively).

The median LOS was 5.05 days (range 3-12). In particular, 16 studies reporting an operative time longer
than 250 min revealed greater LOS, overall and major complications. Among these 16 articles, the median
operative time was 294.2 min (range 251.5-491) and the corresponding median LOS was 6.4 days (range
3.9-12), overall complications rate was 9% (range 1-36) and major complications rate was 3.5 % (range
1-12).

Hospital costs for RS
Many studies documented the costs of robotic liver resections, which were higher than laparoscopy, but
lower than open surgery. Daskalaki et al. published a retrospective single center comparative study
[12]
between robotic and open liver surgery, describing higher average costs for open surgery ($37,518 vs.
$41,948) including readmissions costs, mainly because of the significant impact of ICU stay, inpatient
[23]
nursing, and pharmacy costs. Similarly, Sham et al. revealed higher perioperative costs, but significantly
lower postoperative and total hospital direct costs for RS ($14,754 vs. $18,998), encouraging the
development of RS.