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Page 2 of 6 Ishizawa et al. Mini-invasive Surg 2021;5:52 https://dx.doi.org/10.20517/2574-1225.2021.81

Figure 1. Trends of annual numbers of laparoscopic hepatectomies in Japan (1993-2019). Since the first insurance reimbursement in
2010, the numbers of laparoscopic hepatectomies have progressively increased, and this increase has been further boosted by the
extension of insurance support to a wider range of hepatectomy procedures in 2016. This figure was created based on the 15th
Nationwide Survey of Endoscopic Surgery.

followed by extension of its indications to all LH procedures except hepatectomy requiring biliary
[1]
reconstruction in 2016 and reimbursement of robot-assisted distal pancreatectomy and
pancreaticoduodenectomy in 2020. As of 2021, however, robot-assisted hepatectomy (RAH) has not been
reimbursed. We herein introduce the current status of minimally invasive hepatectomy in Japan and discuss
the potential advantages of RAH over conventional hepatectomy procedures in an effort to promote future
proliferation of robot-assisted hepatobiliary surgery.

CURRENT DISSEMINATION STATUS OF RAH IN JAPAN
Since the first insurance reimbursement in 2010, the number of LH cases in Japan has progressively
increased, and this increase was further boosted by the extension of insurance support to a wider range of
hepatectomy procedures in 2016 [Figure 1]. Based on the National Clinical Database, 13% of hepatectomy
procedures (more than one segment excluding the lateral segment) were performed laparoscopically in
2019 . In contrast, RAH has rarely been performed in Japan; according to the 15th Nationwide Survey of
[2]
Endoscopic Surgery, RAH accounted for only 0.5% of all minimally invasive hepatectomy procedures
performed in 459 medical centers belonging to the Japan Society for Endoscopic Surgery [Table 1, The 15th
Nationwide Survey of Endoscopic Surgery in Japan (The Japanese Society for Endoscopic Surgery)]. In
Japan, where all citizens receive medical care under the universal health insurance system, insurance
reimbursement is critical for both patients and surgeons to ensure access to newly developed therapeutic
modalities such as robot-assisted surgery.

Another feature to consider in the dissemination of RAH is the safety of hepatectomy in Japan. Even after
the nationwide establishment of LH, the overall mortality rates after hepatectomy remained quite low
(0.7%-1.4% at 30 days and 1.3%-2.6% at 90 days from 2011 to 2019), with favorable morbidity rates (3.4%-
[2]
4.3% Clavien-Dindo grade IIIa-V complications) . Step-by-step establishment of LH under the board
certification systems provided by the Japan Society for Endoscopic Surgery , the Japanese Society of
[3]