Photo of robotic surgery machine at a hospital.

Robotic surgery proves powerful for liver cancer

A cohort study found that robotic total liver resection was safe and effective for patients with hepatocellular carcinoma (HCC) compared to open hepatectomy.

The propensity score-matched analysis showed “better tolerability of surgery … based on clinical, oncological, and technical criteria” than with open resection, reported Fabrizio Di Benedetto, MD, of the University of Modena and Reggio Emilia in Modena, Italy, and colleagues.

Robotic hepatectomy had longer operation times (295 vs 200 minutes, including fusion, s<0.001) but for a shorter stay period (4 vs 10 days, s<0.001) and lower ICU admissions (6.6% vs. 19.8%, s= 0.002).

The incidence of liver failure after hepatectomy is also lower than with open resection (7.5% vs. 28.3%, s= 0.001), without any grade C failures, the authors wrote in JAMA surgery.

Complication rates after surgery were generally similar between groups, but open resection patients had a higher risk of severe complications based on the Clavien-Dindo score (11.3% vs 2.8%, s= 0.029).

The group concluded that robotic hepatectomy “may reduce morbidity rates, and potentially increase the number of patients able to receive treatment from which they are currently excluded because of the risk of liver decompensation.”

Overall survival was similar at 90 days between the robotic and open surgery (99.1% vs 97.1%) but at 24 months was actually numerically better in the robotic group (86.9% vs 83.8%).

Mortality related to tumor recurrence was similar between the robotic and open surgery groups at 24 months (8.8% vs 10.2%). A sensitivity analysis that included all relevant prognostic factors also found similar overall survival outcomes.

Although minimally invasive liver surgery has been shown to be safe and effective in removing primary and metastatic liver tumors, there is still more to learn about complex laparoscopic resections, according to Di Benedetto’s group. Robotic hepatectomy is a minimally invasive approach that may reduce the risk of switching to open resection for complex liver resections.

Robotic surgery Resection of the right or previously extended liver has shown more benefits than laparoscopic surgery. Despite the many technical advantages of robotic surgery—such as increased stability, instrument flexibility, and augmented 3D vision—long-term oncological outcomes are still debated, and costs are known to be higher than conventional surgery.

While the researchers were unable to perform a cost-effectiveness analysis in this study, they did point to the counterintuitive advantage of an average difference of 6 days of hospitalization between the intervention groups, writing that it “represents a significant cost saving for any hospital,” as well as fewer of admissions to the intensive care unit and severe complications.

In this study, Di Benedetto and colleagues retrospectively examined the data of 398 patients who underwent robotic (n = 158) or open (n = 240) hepatectomy for HCC from January 1, 2010 to September 30, 2020.

After propensity score matching, 106 robotic resection patients were treated at four centers in Europe and the United States with 106 patients who underwent open resection at an international liver cancer surgery referral center in Italy experienced in non-robotic, minimally invasive surgery,” to reduce bias. Potential selection of robotic centers.

For robotic procedures, a da Vinci Si or Xi platform was used, with a parenchymal cut performed via a Kelly clamp crush technique using advanced ultrasound or radiofrequency hemostasis power devices. Tumor mapping was performed using indocyanine green (ICG) fluorescence for visualization at a dose of 0.25 mg/kg 12 h before surgery or 1 mg ICG upon induction.

Before slope matching, mean age was younger among patients in robotic surgery hospitals than in the open resection hospital validation cohort (66 vs 70). About 79% of the patients were men. After propensity score matching, the mean age was 67-69 and the cohort included 80-83% men. The mean BMI ranged from 26 to 28. Notably, 3.2% of the robotic surgery group underwent intraoperative conversion for open resection.

No significant differences were seen in blood transfusions between groups (8.5% for both) or in the amount of packed red blood cell units transfused (8.5% for both).

Di Benedetto’s group wrote that propensity score matching made the two groups “homogeneous on the basis of not only baseline characteristics but also surgical difficulty and preoperative risk of tumor recurrence, representing an important improvement in this type of analysis.”

However, the authors also acknowledged limitations, including potential bias arising from the non-randomised, retrospective study design.

  • Zeina Hamza He is a writer for MedPage Today, covering gastroenterology and infectious diseases. She resides in Chicago.


Di Benedetto and co-authors disclose no competing interests.

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