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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 7 of 15

Other types of resection
Among the 25 articles reviewed, the numbers of major and minor robotic resections included were 395
and 694 (63.7% and 36.3%) respectively, while laparoscopic cases were 460 and 1,002 (68.5% and 31.5%),
respectively.

Three papers focused on only major hepatectomies (174 robotic vs. 189 laparoscopic cases). Among
[24]
these, Fruscione et al. revealed that robotic technical advantages could improve surgical outcomes
in comparison with laparoscopy, reducing postoperative ICU admissions (43.9% vs. 61.2%) and 90-day
readmissions (7% vs. 28.5%), with a similar median complications rate (28.1% vs. 35.3%) and median LOS
(4 days vs. 5 days).

Many authors focused on the ability of RS to overcome laparoscopic drawbacks, particularly simplifying
hilar and hepatocaval dissection, suturing and anastomosis, precise vessel dissection or advanced sewing.
However, the numbers of complex parenchymal sparing resections involving postero-superior segments or
caudate lobe were similar for RS and laparoscopy, 112 (10.7%) vs. 235 (16.9%), respectively.

In complex cases many comparative studies demonstrated similar safety, feasibility and postoperative
outcomes, but RS was preferred over laparoscopy, especially when several and multiplanar transection lines
were necessary, resulting in safe surgical margins and increasing the rate of MIS resections [2,21,26] . In the
future these advantages could encourage the choice of RS in challenging cases, otherwise not feasible by
laparoscopy [40,41] .

Surgery related factors
Considering the 25 articles reviewed, the median EBL for RS and laparoscopy were 261 mL vs. 290 mL
(range 30-465 vs. 30-457, respectively). Only three studies reported statistically significant differences of
[43]
[42]
this parameter. Wu et al. and Troisi et al. reported greater EBL for RS (325 mL vs. 173 mL and 330 mL
[31]
vs. 174 mL, respectively), in contrast with Wang et al. (243 mL vs. 346 mL).
[2]
Referring to the use of the Pringle maneuver, Montalti et al. reported its significant use during RS
compared to in laparoscopy (55.6% vs. 22.2%, respectively) because of the crush technique, leading
to a longer inflow occlusion time and greater severity of complications, evaluated by comprehensive
complication index (CCI: 34.6% vs. 18.4%). Conversely, Spampinato et al. published a retrospective
[36]
comparative multi-institutional study, demonstrating that RS allowed for easier management of bleeding
during the transection, making the application of the Pringle maneuver less necessary and reporting a
significantly higher EBL for laparoscopy compared to RS (400 mL vs. 250 mL, respectively).

The median operative time for RS and laparoscopy was 271 min (range 107-430) and 227 min (range
96-360), respectively. Ten studies reported statistically significant longer duration with RS compared to
[36]
laparoscopy, with a mean additional time of 68 min (range 34-153) [1,6,14,16,21,37,39,42,44,45] . Spampinato et al.
specified that longer robotic operative time could be related to instrument replacement and docking time,
which could be reduced by improving the training of the surgical team.

In 18 articles the median operative time was longer than 250 min for RS and/or laparoscopy. In these
studies, although the frequency of minor resections (69.6% vs. 74.3%, respectively), EBL (293 mL vs. 292.5 mL,
respectively), LOS (6.7 days vs. 6.2 days, respectively) and overall complications rates (16% vs. 15.7%,
respectively) were similar between RS and laparoscopy, the conversion rate (5% vs. 9.25%, respectively) was
lower for RS. These results suggest that RS could increase MIS approach also in complex cases requiring
longer operative time.