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Robotic surgery for a right or extended right hepatectomy showed benefits over laparoscopic surgery, a retrospective study found.

Among 220 matched patient pairs, robotic surgery was associated with a reduced open conversion rate (8.6% vs 17.7%, P=0.01) and a shorter postoperative stay (mean 9.1 vs 9.9 days, P=0.048) compared with laparoscopic surgery, reported Brian Goh, MBBS, MMed, of Singapore General Hospital, and colleagues.

A subset analysis performed after a center's learning curve of 50 cases confirmed shorter length of stay with robotic surgery (median 6 vs 7 days, P=0.04), but showed no significant difference in conversion rates (7.6% vs 10.8%, P=0.46), Goh and co-authors wrote in .

"After reduction of the learning curve effect, robotic RH/ERH [right hepatectomy or extended right hepatectomy] was associated with a shorter hospital stay and similar perioperative outcomes," they stated. "Our results imply that a robotic approach may help to overcome the learning curve in RH/ERH at the initial phase."

This is the largest series to date of minimally invasive right and extended right hepatectomies, noted Allan Tsung, MD, of Ohio State University Wexner Medical Center in Columbus, and co-authors in an .

"The robotic platform is not only safe and feasible for major hepatectomies but also provides benefits earlier in the learning curve," Tsung and colleagues wrote.

"These results for major hepatectomy stand in contrast to the results of the Effect of Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer () randomized clinical trial, which showed no difference in the rate of conversion to open hepatectomy between robotic and laparoscopic surgery for rectal cancer," the editorialists observed, noting some of those surgeons had not yet passed the robotic surgery learning curve.

Robotic surgery has allowed more major hepatectomies to be done with a minimally invasive technique, Goh and co-authors noted. Prior meta-analyses have investigated robotic versus laparoscopic hepatectomy but had confounding factors. A limited number of studies have explored major hepatectomies specifically involving right hepatectomy or extended right hepatectomy.

Goh and colleagues examined data on 989 patients who underwent a robotic (n=220) or laparoscopic (n=769) right hepatectomy (93-96%) or extended right hepatectomy (4-7%) from January 2008 to December 2020 at 29 international centers. Patients who underwent laparoscopic-assisted or hand-assisted procedures, transplants, related liver-partition, or portal vein ligation were excluded, among others.

Propensity score matching was used to analyze 440 patients matched 1:1, based on sex, age at surgery, resection year, tumor size, (ASA) status, and other factors.

Patients in the robotic group and the laparoscopic group had a similar median age (61 vs 62, respectively) and most were men (63-64%). The vast majority of patients were undergoing surgery for a malignancy (86-88%), three-fourths stemming from hepatocellular carcinoma or colorectal cancer liver metastases. The robotic group had more patients with an ASA score of III/IV (40% vs 24%), but fewer patients with prior abdominal (34% vs 42%) or liver surgery (4% vs 12%) and multiple tumors (26% vs 40%).

No significant differences were seen in average operative time (315 vs 345 minutes), blood loss (300 vs 300 mL), or other perioperative outcomes. The robotic group had less overall postoperative morbidity (31% vs 38%) and major morbidity than the laparoscopic group (11% vs 17%, respectively).

Right or extended right hepatectomy operative times can be long and robotic surgery can alleviate a surgeon's fatigue, but access is limited and the cost of the procedure is high, the researchers noted.

The authors acknowledged several limitations to the data, including potential information and selection bias. Post-operative length of stay may be attributed to multiple confounding factors. Information on whether surgeons had prior experience with robotic surgery was unavailable.

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