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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 11 of 15

Table 6. Robotic surgery for colorectal liver metastases
First Author Cases Age Location Major/ Simultaneous EBL Time Conversion R0 LoS Overall/major DFS/OS
minor complications
Guerra et al. [18] 59 64 LS, PS 4/78 4 200 210 12 92 6.7 27/5 3-year:
41.9/66.1
Beard et al. [26] 115 61 LS, PS 97/18 - - 272* 5.2 73.7 5 31.3/10.4 5-year:
38/61
Guadagni et al. [34] 20 66 LS 0/20 3 250* 198* 0 100 4.7 25/0 3-year:
35.8/-
Lin et al. [49] 25 58.5 LS 3/22 25 271 319 - 100 7.5 24/- -
Araujo et al. [54] 5 59 PS 0/5 - 160* 294* 0 100 4 20/0 -
Dwyer et al. [55] 6 59.3 - 0/6 6 316 401 0 100 4.5 33.3/- -
Navarro et al. [56] 12 59 LS, Sg1 4/8 16 274 449 0 100 12 41/16.6 -
Cases: number of patients. Lesions’ location: PS: postero-superior segments; LS: laparoscopic segments different from the postero-
superiors. Major/minor resections: number of major/minor, according to the description of the Authors or calculated from the data
supplied. Simultaneous: resection of the primary and secondary tumors simultaneously. 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

In conclusion, these outcomes could support the use of RS, despite the high operative time and costs.

CONCLUSION
In the field of hepatobiliary surgery, use of the robotic approach is promising, but not standardized yet.
International and multicenter studies are limited, only few publications reported long-term outcomes and
no randomized trials are available in literature. In the current literature many authors attempted to reach
definitive conclusions about the use of RS publishing many reviews/meta-analyses. In general, almost all of
these studies found RS as safe and effective with acceptable morbidity in the treatment of liver malignancies
as for laparoscopy [7,57-59] . Furthermore many authors agreed with the necessity of specific training in RS, the
high costs and the usefulness of RS in complex cases, such as cirrhotic patients and in complex surgical
procedures including microsuturing, biliary dissection, and bilio-enteric anastomosis [59,60] . However
many results of RS are still discordant, mainly in short-term outcomes, and no studies reported definitive
indications and contraindications of RS because of the lack of randomized control trials. The comparison
among open, laparoscopic, and robotic liver resections demonstrated that the robotic approach achieved
similar results to other MIS techniques, enhancing patients’ recovery after surgery.

The majority of the studies reported single center initial experiences and considered the robotic learning
curve shorter than the laparoscopic one, especially for surgeons with advanced skills in open liver
[21]
surgery [21,22,29,33] . Efanov et al. established that 8-10 robotic procedures can be adequate to significantly
increase the surgeons’ experience and the ability to perform difficult procedures.

[22]
Choi et al. reported results from single center and single surgeon’s activity, emphasizing the usefulness
of high experience on open liver surgery to approach the robotic resections, making safe and feasible all
types of anatomic liver resections, even more complex ones, such as staged hepatectomy and living donor
[33]
right hepatectomy. Ceccarelli et al. , describing their robotic learning curve program organized in a
network between high and low volume centers, demonstrated that this strategy provides a proper standard
of care without the need of reaching referral centers for the patients, even in particularly complex cases. In
addition, this protocol can improve surgical skills, shortening the learning curve.

Interestingly, Lai et al. reviewed the learning curves of robotic and laparoscopic hepatectomy and
[61]
concluded that a qualified robotic surgeon should have great knowledge of liver anatomy, enough
experience in open liver surgery and in the management of its major complications and a good training in
both laparoscopic and robotic surgery.