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Introduction: The ability to stratify the difficulty of minimally invasive liver resection (MILR) allows surgeons at different phases of the learning curve to tackle cases of appropriate difficulty safely. Several difficulty scoring systems (DSS) have been formulated which attempt to accurately stratify this difficulty. The present study aims to review the literature pertaining to the existing DSS for MILR., Methods: We performed a systematic review and metanalysis of the literature reporting on the formulation, supporting data, and comparison of DSS for MILR., Results: A total of 11 studies were identified which reported on the formulation of unique DSS for MILR. Five of these (Ban, Iwate, Hasegawa, Institut Mutaliste Montsouris [IMM], and Southampton DSS) were externally validated and shown to predict difficulty of MILR via a range of outcome measures. The Ban DSS was supported by pooled data from 10 studies (9 LLR, 1 RLR), Iwate by 10 studies (8 LLR, 2 RLR), Hasegawa by four studies (all LLR), IMM by eight studies (all LLR), and Southampton by five studies (all LLR). There was no clear superior DSS., Conclusion: The existing DSS were all effective in predicting difficulty of MILR. Present studies comparing between DSS have not established a clear superior system, and the five main DSS have been found to be predictive of difficulty in LLR and two of these in RLR., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Objective: The purpose of this study was to compare the outcomes of robotic limited liver resections (RLLR) versus laparoscopic limited liver resections (LLLR) of the posterosuperior segments., Background: Both laparoscopic and robotic liver resections have been used for tumors in the posterosuperior liver segments. However, the comparative performance and safety of both approaches have not been well examined in the existing literature., Methods: This is a post hoc analysis of a multicenter database of 5446 patients who underwent RLLR or LLLR of the posterosuperior segments (I, IVa, VII, and VIII) at 60 international centers between 2008 and 2021. Data on baseline demographics, center experience and volume, tumor features, and perioperative characteristics were collected and analyzed. Propensity score-matching (PSM) analysis (in both 1:1 and 1:2 ratios) was performed to minimize selection bias., Results: A total of 3510 cases met the study criteria, of whom 3049 underwent LLLR (87%), and 461 underwent RLLR (13%). After PSM (1:1: and 1:2), RLLR was associated with a lower open conversion rate [10 of 449 (2.2%) vs 54 of 898 (6.0%); P =0.002], less blood loss [100 mL [IQR: 50-200) days vs 150 mL (IQR: 50-350); P <0.001] and a shorter operative time (188 min (IQR: 140-270) vs 222 min (IQR: 158-300); P <0.001]. These improved perioperative outcomes associated with RLLR were similarly seen in a subset analysis of patients with cirrhosis-lower open conversion rate [1 of 136 (0.7%) vs 17 of 272 (6.2%); P =0.009], less blood loss [100 mL (IQR: 48-200) vs 160 mL (IQR: 50-400); P <0.001], and shorter operative time [190 min (IQR: 141-258) vs 230 min (IQR: 160-312); P =0.003]. Postoperative outcomes in terms of readmission, morbidity and mortality were similar between RLLR and LLLR in both the overall PSM cohort and cirrhosis patient subset., Conclusions: RLLR for the posterosuperior segments was associated with superior perioperative outcomes in terms of decreased operative time, blood loss, and open conversion rate when compared with LLLR., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The adoption of robotic techniques in liver surgery introduces significant challenges for their safe integration within hepatobiliary surgery units. This study is designed to investigate the complexities associated with establishing a robotic surgery program., Methods: Data on robotic hepatobiliary surgeries were prospectively collected from October 2021 to October 2023. Historical cohorts from the institutional experiences for comparison were hand-assisted (HALS) and purely laparoscopic procedures (PLS). Inverse probability of treatment weighting and propensity score matching were employed to compare outcomes between PLS and robotic resections. The learning curve for robotic surgeries was evaluated by the cumulative sum method., Results: In this study, 454 patients were enrolled (113 robotic surgeries, 157 HALS, and 184 PLS). The posterosuperior segments resections were significantly higher in the robotic group (47.8%) compared to PLS (31.5%) and HALS (35.7%). There were no conversions in the robotic group, in PLS 2.7% and HALS 3.8%. The degree of difficulty according to the median of the IWATE score and IMM score was significantly higher in the robot group (p < 0.001 and p = 0.008, respectively). No significant differences in short-term outcomes were observed between robotic procedures and PLS in a matched subset of patients. Operative efficiency and blood loss improved significantly after the 75th robotic surgery patient, with high-difficulty cases (IWATE ≥ 10) incorporated from the beginning., Conclusion: This study suggests that robotic liver surgery in units with prior experience in minimally invasive liver surgery offers benefits, such as a lower conversion rate and a higher rate of successful difficult resections., Competing Interests: Declarations. Conflict of interest: Victor López-López, Ignacio Sánchez-Esquer, Christoph Kuemmerli, Roberto Brusadin, Asunción López-Conesa, Álvaro Navarro, Patricia Pastor, Leonid Omar Carrión Retuerto, María Iniesta and Ricardo Robles-Campos have no conflicts of interest or financial ties to disclose., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Transduodenal Ampullectomy (TA) is a procedure for resecting low-malignancy ampullary tumors, with postoperative fistula as a notable complication. This study aims to clarify the indications for TA, outline the surgical robotic technique, and emphasize the importance of comprehensive complication management alongside the surgical approach. This multimedia article provides a detailed exposition of the robotic TA surgical technique, including the most important steps involved in exposing and reimplanting biliary and pancreatic ducts. The procedure encompasses the mobilization of the hepatic flexure of the colon, an extensive Kocher maneuver for duodenal mobilization, and ampulla exposure through a duodenal incision. Employing retraction loop sutures enhances surgical field visibility. Reconstruction involves securing pancreatic and biliary ducts to the duodenal mucosa, each tutored with a silicon catheter, and suturing for ampullectomy completion. The total operative time was 380 min. Final histopathology disclosed high-grade dysplasia with an isolated focus of adenocarcinoma (pT1), accompanied by clear resection margins. A postoperative duodenal fistula occurred, managed successfully through conservative treatment, utilizing subcutaneous drainage. Despite accurate robotic TA execution, complications may arise. This study underscores the importance of a comprehensive approach, incorporating meticulous surgical technique and effective complication management, to optimize patient outcomes., (© 2024. Italian Society of Surgery (SIC).)

Background: For open minor hepatectomy, morbidity and recovery are dominated by the incision. The robotic approach may transform this "incision dominant procedure" into a safe outpatient procedure., Study Design: We audited outpatient (less than 2 midnights) robotic hepatectomy at 6 hepatobiliary centers in 2 nations to test the hypothesis that the robotic approach can be a safe and effective short-stay procedure. Establishing early recovery after surgery programs were active at all sites, and home digital monitoring was available at 1 of the institutions., Results: A total of 307 outpatient (26 same-day and 281 next-day discharge) robotic hepatectomies were identified (2013 to 2023). Most were minor hepatectomies (194 single segments, 90 bi-segmentectomies, 14 three segments, and 8 four segments). Thirty-nine (13%) were for benign histology, whereas 268 were for cancer (33 hepatocellular carcinoma, 27 biliary, and 208 metastatic disease). Patient characteristics were a median age of 60 years (18 to 93 years), 55% male, and a median BMI of 26 kg/m 2 (14 to 63 kg/m 2 ). Thirty (10%) patients had cirrhosis. One hundred eighty-seven (61%) had previous abdominal operation. Median operative time was 163 minutes (30 to 433 minutes), with a median blood loss of 50 mL (10 to 900 mL). There were no deaths and 6 complications (2%): 2 wound infections, 1 failure to thrive, and 3 perihepatic abscesses. Readmission was required in 5 (1.6%) patients. Of the 268 malignancy cases, 25 (9%) were R1 resections. Of the 128 with superior segment resections (segments 7, 8, 4A, 2, and 1), there were 12 positive margins (9%) and 2 readmissions for abscess., Conclusions: Outpatient robotic hepatectomy in well-selected cases is safe (0 mortality, 2% complication, and 1.6% readmission), including resection in the superior or posterior portions of the liver that is challenging with nonarticulating laparoscopic instruments., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Despite the advances in minimally invasive (MI) liver surgery, most major hepatectomies (MHs) continue to be performed by open surgery. This study aimed to evaluate the risk factors and outcomes of open conversion during MI MH, including the impact of the type of approach (laparoscopic vs. robotic) on the occurrence and outcomes of conversions., Methods: Data on 3880 MI conventional and technical (right anterior and posterior sectionectomies) MHs were retrospectively collected. Risk factors and perioperative outcomes of open conversion were analyzed. Multivariate analysis, propensity score matching, and inverse probability treatment weighting analysis were performed to control for confounding factors., Results: Overall, 3211 laparoscopic MHs (LMHs) and 669 robotic MHs (RMHs) were included, of which 399 (10.28%) had an open conversion. Multivariate analyses demonstrated that male sex, laparoscopic approach, cirrhosis, previous abdominal surgery, concomitant other surgery, American Society of Anesthesiologists (ASA) score 3/4, larger tumor size, conventional MH, and Institut Mutualiste Montsouris classification III procedures were associated with an increased risk of conversion. After matching, patients requiring open conversion had poorer outcomes compared with non-converted cases, as evidenced by the increased operation time, blood transfusion rate, blood loss, hospital stay, postoperative morbidity/major morbidity and 30/90-day mortality. Although RMH showed a decreased risk of conversion compared with LMH, converted RMH showed increased blood loss, blood transfusion rate, postoperative major morbidity and 30/90-day mortality compared with converted LMH., Conclusions: Multiple risk factors are associated with conversion. Converted cases, especially those due to intraoperative bleeding, have unfavorable outcomes. Robotic assistance seemed to increase the feasibility of the MI approach, but converted robotic procedures showed inferior outcomes compared with converted laparoscopic procedures., (© 2023. Society of Surgical Oncology.)

Sectionectomy is a parenchma-sparing alternative to (extended) right or left hemihepatectomy. However, the effectiveness and safety of robotic sectionectomy (RS) versus robotic (extended) hemihepatectomy (RH) for the treatment of liver tumors remains unclear. We reviewed our prospective database for consecutive patients who had undergone robotic hepatectomies between March 2021 and July 2023 and included all patients with RS and RH. Demographic data, perioperative outcomes and long-term outcomes were analyzed and compared between both groups. Thirty patients met our inclusion criteria, of whom 16 patients underwent RS as opposed to 14 patients who underwent RH. Baseline characteristics were comparable between the study groups. The duration of Pringle maneuver was significantly longer in the RS group, while the remaining operative details were comparable. There were no significant differences in posthepatectomy outcomes between the study groups. All patients had negative resection margins. RS is a safe and effective parenchyma-sparing treatment modality., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: Robotic platform has been increasingly applied in major hepatectomy. However, the role or advantage of robotic approach comparing with laparoscopic approach in major hepatectomy remains controversial. This meta-analysis compares perioperative outcomes of robotic major hepatectomy (RMH) to laparoscopic major hepatectomy (LMH) for hepatic neoplasms., Methods: PubMed, Web of Science, EMBASE, and Cochrane Library were searched to identify comparative studies compared RMH versus LMH for hepatic neoplasms. The search timeframe was set before May 2023. Main outcomes were mortality, overall morbidities, serious complications, and conversion to open surgery. Secondary outcomes were operative time, intraoperative blood loss, blood transfusion, postoperative length of hospital stay, R0 resection, reoperation, and readmission. Studies were evaluated for quality by Cochrane risk of bias tool or Newcastle-Ottawa scale. Data were pooled as odds ratio (OR) or mean difference (MD). This study was registered at PROSPERO (CRD42023410951)., Results: Twelve retrospective cohort studies concerning total 1657 patients (796 RMH, 861 LMH) were included. Meta-analyses showed no significant differences in mortality (OR=1.23, 95% CI=0.50-2.98, P =0.65), overall postoperative complications (OR=0.83, 95% CI=0.65-1.06, P =0.14), operative time (MD=6.47, 95% CI=-14.72 to 27.65, P =0.55), blood transfusion (OR=0.77, 95% CI=0.55-1.08, P =0.13), R0 resection (OR=1.45, 95% CI=0.91-2.31, P =0.12), reoperation (OR=0.76, 95% CI=0.31-1.88, P =0.56), and readmission (OR=0.63, 95% CI=0.28-1.44, P =0.27) between RMH and LMH. Incidence of serious complications (OR=0.60, 95% CI=0.40-0.90, P =0.01), conversion to open surgery (OR=0.41, 95% CI=0.27-0.63, P <0.0001), blood loss (MD=-91.42, 95% CI=-142.18 to -40.66, P =0.0004), and postoperative hospital stay (MD=-0.64, 95% CI=-0.78 to -0.49, P <0.00001) were reduced for RMH versus LMH., Conclusions: RMH is associated with comparable short-term surgical outcomes and oncologic adequacy compared to LMH when performed by experienced surgeons at large centres. RMH may result in reduced major morbidities, conversion rate, blood loss, and hospital stay, but these results were volatile. Further randomized studies should address the potential advantages of RMH over LMH., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To compare the outcomes between robotic major hepatectomy (R-MH) and laparoscopic major hepatectomy (L-MH)., Background: Robotic techniques may overcome the limitations of laparoscopic liver resection. However, it is unknown whether R-MH is superior to L-MH., Methods: This is a post hoc analysis of a multicenter database of patients undergoing R-MH or L-MH at 59 international centers from 2008 to 2021. Data on patient demographics, center experience volume, perioperative outcomes, and tumor characteristics were collected and analyzed. Both 1:1 propensity-score matched (PSM) and coarsened-exact matched (CEM) analyses were performed to minimize selection bias between both groups., Results: A total of 4822 cases met the study criteria, of which 892 underwent R-MH and 3930 underwent L-MH. Both 1:1 PSM (841 R-MH vs. 841 L-MH) and CEM (237 R-MH vs. 356 L-MH) were performed. R-MH was associated with significantly less blood loss {PSM:200.0 [interquartile range (IQR):100.0, 450.0] vs 300.0 (IQR:150.0, 500.0) mL; P = 0.012; CEM:170.0 (IQR: 90.0, 400.0) vs 200.0 (IQR:100.0, 400.0) mL; P = 0.006}, lower rates of Pringle maneuver application (PSM: 47.1% vs 63.0%; P < 0.001; CEM: 54.0% vs 65.0%; P = 0.007) and open conversion (PSM: 5.1% vs 11.9%; P < 0.001; CEM: 5.5% vs 10.4%, P = 0.04) compared with L-MH. On subset analysis of 1273 patients with cirrhosis, R-MH was associated with a lower postoperative morbidity rate (PSM: 19.5% vs 29.9%; P = 0.02; CEM 10.4% vs 25.5%; P = 0.02) and shorter postoperative stay [PSM: 6.9 (IQR: 5.0, 9.0) days vs 8.0 (IQR: 6.0 11.3) days; P < 0.001; CEM 7.0 (IQR: 5.0, 9.0) days vs 7.0 (IQR: 6.0, 10.0) days; P = 0.047]., Conclusions: This international multicenter study demonstrated that R-MH was comparable to L-MH in safety and was associated with reduced blood loss, lower rates of Pringle maneuver application, and conversion to open surgery., Competing Interests: B.K.P.G. has received travel grants and honorariums from Johnson and Johnson, Olympus and Transmedic, the local distributor for the Da Vinci Robot. M.V.M. is a consultant for CAVA robotics LLC. J.P. reports a research grant from Intuitive Surgical Deutschland GmbH and personal fees or non-financial support from Johnson and Johnson, Medtronic, AFS Medical, Astellas, CHG Meridian, Chiesi, Falk Foundation, La Fource Group, Merck, Neovii, NOGGO, pharma-consult Peterson, and Promedicis. M. Schmelzle reports personal fees or other support outside of the submitted work from Merck, Bayer, ERBE, Amgen, Johnson and Johnson, Takeda, Olympus, Medtronic, and Intuitive. A.A.F. reports receiving speaker fees from Bayer. F.R. reports speaker fees and support outside the submitted work from Integra, Medtronic, Olympus, Corza, Sirtex, and Johnson and Johnson. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)