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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 9 of 15

Table 3. Robotic surgery for hepatocellular carcinoma
Authors Cases Age Location Major/ EBL Time Conversion Cirrhosis R0 LoS Overall/major DFS/OS
minor complications
Magistri et al. [6] 22 60.8 LS, PS 2/20 400 318* 0 68 95 5.1 68/9 -
Lai et al. [16] 95 62.1 LS, PS 27/75 335 207 4 84 96 7.3* 14/1 5-year: 42/65
Lim et al. [25] 42 - - - - - 0 - 97 - - 3-year: 64/98
Chen et al. [28] 81 - - 34/47 282 343 - 46 97 7.5 5/0 3-year: 72/93
Wu et al. [42] 38 60.9 LS - - 380 5 - - 7.9 8/- -
Han et al. [50] 16 54.5 LS 10/16 389 285 0 53 100 8.4 - -
Cases: number of patients. Lesions’ location: PS: postero-superior segments; LS: laparoscopic segments different from the postero-
superiors. OS: overall survival; DFS: disease free survival. Major/minor resections: number of major/minor, according to the description of
the authors or calculated from the data supplied. EBL: milliliters (median/*mean). Operative time: minutes (median/*mean). Conversion
rate: percentage of procedures converted to open surgery. R0: percentage of negative margin status. LoS: days (median/*mean). Overall/
major complications: percentage of all complications/major complications. DFS and OS: percentage at 3-/5-year. “-”: not reported

LOS, improved patients’ pain control, not compromising oncologic outcomes and reaching comparable
[16]
[6]
3-years DFS (72.2% vs. 58.0%) and 3-years OS (92.6% vs. 93.7%). Magistri et al. and Lai et al. reported
less minor robotic postoperative complications, such as pleural effusion, thanks to gentler manipulation
of the diaphragm, especially in the case of lesions located in postero-superior segments. In addition, RS
allowed lower rates of conversion, a greater number of resections involving the postero-superior segments,
and resections of slightly larger tumors, that could explain the higher rate of major hepatectomies. Lai et al.
[16]
did not find significant differences between robotic and laparoscopic oncologic outcomes (5-years OS:
65% vs. 48%, respectively), morbidity and mortality. The authors concluded that robotic MIS was a valid
alternative treatment for HCC in selected patients and in the hands of surgeons expert in laparoscopic and
robotic liver surgery, following the principles of open liver surgery.

Likewise, Han et al. revealed the safety and feasibility of the robotic approach to complex procedures and
[50]
anatomical liver resections, and thus the superiority of minimally invasive liver surgery in terms of EBL,
complication rate, LOS and risk of ascites, maintaining DFS and OS similar to open surgery.

Gallbladder cancer
RS seems particularly advantageous in the treatment of GBC, overcoming the difficulties related to the
laparoscopic approach. Focusing on this field, 4 articles including 51 patients were reviewed [Table 4].
[19]
[48]
Zeng et al. demonstrated safety and feasibility of both robotic and laparoscopic surgery. Otherwise, Goel et al.
and Byun et al. compared results of robotic and open radical cholecystectomy. They achieved similar
[51]
results between the two approaches, reaching no significant differences in operative time, EBL and number
[52]
of retrieved lymph nodes, with a reduction of LOS. Likewise, Shen et al. confirmed the feasibility of a
complete robotic lymphadenectomy of the hepatic artery, the celiac axis, the hepatoduodenal ligament and
retropancreatic nodes, in contrast with laparoscopy. In addition, robotic approach could reduce the risk of
major iatrogenic injuries and major bleeding could be more easily managed [51,52] .

In conclusion, in selected cases RS for GBC is considered safe, feasible and effective, even during the initial
learning curve, allowing sufficient lymph node dissection and enhancing recovery [19,51,52] .

Hilar cholangiocarcinoma
Even if the advantages of the robotic technique for procedures that require extreme precision and
microanastomosis are clear, the scientific literature is lacking in reports about robotic treatment of this
disease. Probably further implementation in surgeon expertise and robotic tools are necessary to reach
encouraging results that could increase its use. Two articles were selected and their data tabulated [Table 5].

Li et al. highlighted the feasibility of 48 robotic resections for Bismuth-Corlette type I, II or III hilar
[17]
cholangiocarcinoma. The authors considered RS a valid alternative to open surgery in selected cases,