Related Experiment Video
Updated: May 5, 2026
Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst
Published on: June 24, 2022
Robotic-assisted versus laparoscopic versus open liver resection: comparison of postoperative outcomes according to
Schaima Abdelhadi1, Mohamad El-Ahmar2, Sepehr Abbasi Dezfouli2
1Department of Surgery, Medical Faculty Mannheim, Universitätsmedizin Mannheim, Heidelberg University, Mannheim, Germany. schaima.abdelhadi@umm.de.
Background:
Minimally invasive liver surgery (MILS) has become increasingly established, yet the relative benefits of laparoscopic (LLR) and robotic-assisted liver resection (RLR) compared with open liver resection (OLR) across different levels of surgical difficulty remain debated. This study aimed to compare perioperative outcomes of RLR, LLR, and OLR stratified by the IWATE difficulty score.
Methods:
All consecutive patients undergoing elective liver resection between April 2018 and December 2024 at a high-volume hepatobiliary center were retrospectively analyzed from a prospectively maintained database. Patients were stratified into low/intermediate (IWATE 0-6) and advanced/expert (IWATE 7-12) groups. Multivariable regression and interaction term analyses were performed to adjust for confounders and assess the modifying effect of surgical difficulty.
Results:
A total of 686 patients were included: 425 (62%) underwent LLR, 101 (15%) RLR, and 160 (23%) OLR. Of these, 400 (58%) were advanced/expert resections. Minimally invasive approaches were associated with significantly reduced blood loss, morbidity, and length of stay compared with OLR across all IWATE levels. In advanced/expert resections, RLR provided the greatest benefit, with lower major complications (8% vs. 17% LLR vs. 23% OLR) and shorter length of stay (median 6 vs. 9 days OLR). Multivariable analyses confirmed these findings, with both LLR (OR 0.24, 95% CI 0.10-0.55) and RLR (OR 0.24, 95% CI 0.06-1.00) independently associated with reduced major complications compared to OLR. Interaction analyses demonstrated that the comparative advantage of RLR was most pronounced in advanced/expert resections, while LLR showed particular efficiency in low/intermediate cases.
Conclusion:
Both LLR and RLR are safe and effective across all levels of surgical difficulty. RLR, however, offers distinct advantages in technically demanding advanced and expert cases. These findings reinforce the role of MILS as the preferred standard and highlight the importance of tailoring the surgical approach to case complexity.
Insights
Minimally invasive liver surgery (MILS), including laparoscopic (LLR) and robotic-assisted liver resection (RLR), is effective across all difficulty levels. Robotic-assisted liver resection (RLR) offers significant advantages for complex, advanced liver resections.
Area of Science:
- Hepatobiliary Surgery
- Minimally Invasive Surgery
- Surgical Oncology
Background:
- Minimally invasive liver surgery (MILS) is increasingly adopted, but comparisons between laparoscopic (LLR), robotic-assisted (RLR), and open liver resection (OLR) across varying surgical complexities are debated.
- The IWATE difficulty score is used to stratify liver resection complexity.
Purpose of the Study:
- To compare perioperative outcomes of RLR, LLR, and OLR stratified by the IWATE difficulty score.
- To evaluate the impact of surgical difficulty on the relative benefits of different liver resection approaches.
Main Methods:
- Retrospective analysis of 686 consecutive patients undergoing elective liver resection.
- Stratification into low/intermediate (IWATE 0-6) and advanced/expert (IWATE 7-12) difficulty groups.
- Multivariable regression and interaction analyses to adjust for confounders and assess the effect of surgical difficulty.
Main Results:
- MILS (LLR and RLR) demonstrated significantly reduced blood loss, morbidity, and length of stay compared to OLR across all IWATE levels.
- In advanced/expert resections, RLR showed the lowest major complication rates (8%) and shortest length of stay (6 days) compared to LLR (17%, 9 days) and OLR (23%, 9 days).
- Multivariable analyses confirmed LLR and RLR were independently associated with reduced major complications versus OLR; RLR's advantage was most pronounced in advanced cases.
Conclusions:
- Both laparoscopic liver resection (LLR) and robotic-assisted liver resection (RLR) are safe and effective for all surgical difficulty levels.
- Robotic-assisted liver resection (RLR) provides superior benefits for complex, advanced liver resections.
- Tailoring the surgical approach to case complexity is crucial, reinforcing MILS as a preferred standard.
