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Page 8 of 15 Ruzzenente et al. Mini-invasive Surg 2020;4:91 I http://dx.doi.org/10.20517/2574-1225.2020.90

The reported use of hand-port in RS is lower than in laparoscopy. The reason for this observation could be
the distance of the first surgeon from the patient and from the operative field that is mainly occupied by the
robotic arms. Moreover, the second surgeon at the operative table could not have enough surgical skills to
manage unexpected events. This statement could explain also the lower rate of conversion to hybrid robotic
procedures in case of unexpected events. However, many studies reported an easier robotic management of
adhesions and major intraoperative complications as bleeding than in laparoscopy, that could explain the
lower rate of conversion to open surgery for RS.

The median rates of conversion for RS and laparoscopy were 4% vs. 7.35% (both ranges 0-20). Among the
25 comparative articles reviewed, 4 papers reported a statistically significant higher conversion rate for
laparoscopy in comparison with RS [6,26,31] , while the other authors did not reach statistically significant
[43]
results for this variable. Only Troisi et al. found a higher conversion rate for RS compared to laparoscopic
surgery (20% vs. 7.6%, P = 0.034) but, considering only resections of postero-superior segments, they
showed that RS provided a lower conversion rate (20% vs. 35.3%, P = 0.38).

Postoperative outcomes
The median rates of overall robotic and laparoscopic complications were 17.7% vs. 37.6% (ranges 5.7-68.1
vs. 27.2-48), respectively. The median rates of major complications were 2.5% vs. 8.9% (ranges 0-16.6 vs.
0-21.4), respectively.

[21]
The median LOS for RS and laparoscopy were 6 days vs. 5.95 days (ranges 3-11 vs. 3-9.5). Only Efanov et al.
[38]
and Packiam et al. reported a statistically significant longer hospital stay for RS, mainly caused by
postoperative complications and ICU stay.

Comparison of costs
Many authors confirmed the major costs of robotic resections, although the annual service fees could be
[37]
cushioned by the utilization of the robot in other surgical specialties at the same institution. Kim et al.
observed that robotic LLS showed higher costs ($8,183 vs. $5,190) and longer operative time. Salloum et al.
[39]
suggested that robotic LLS did not add additional advantages in comparison with laparoscopic outcomes.
Furthermore, while perioperative costs were higher in the robotic group, total costs were similar in
[46]
comparison with laparoscopy (€5,522 vs. €6,035). Berber et al. calculated a general addition of $500 per
case for the robotic equipment. Ji et al. considered RS not routinely applicable, since its higher costs in
[41]
[38]
comparison with laparoscopy ($12,046 vs. $7,618). Packiam et al. performed a cost analysis differentiating
direct and indirect costs of RS. Only robotic indirect costs were significantly higher, adding $1,423 per case
[47]
($6,553 vs. $4,408). However, Yu et al. concluded that RS could really increase in near future, overcoming
the drawbacks represented by the major costs ($11,475 vs. $6,762) and the absence of transection tools
equivalent to those available in laparoscopy.

Robotic surgery in specific malignant diseases
The majority of the publications in the literature report cumulative results, without differentiation between
benign and malignant diseases. However, in future probably more specific analyses of RS outcomes for each
of the most relevant hepatobiliary malignancies could help in the definition of the standard of care for each
one.

Hepatocellular carcinoma
Robotic resections for HCC are feasible, safe, and demonstrated adequate oncologic outcomes. Six
retrospective papers, including 294 patients, analyzed the results of RS for HCC [Table 3].

[28]
In this field the superiority of robotic MIS over open surgery was confirmed by Chen et al. by a PSM
study. Even in challenging major resections, robotic approach showed longer operative time, but shorter