Transforming robotic hepatectomy outcomes: a comparative analysis before and after ERAS protocol implementation

Since its development, Enhanced Recovery After Surgery (ERAS) protocol has generally improved patient outcomes and enhanced peri-operational organization. The protocol includes less intraoperative invasiveness and enhances perioperative mobility and nutrition. Robotic technology has demonstrated similar benefits, particularly in complex hepatobiliary resections. This study describes comparative outcomes of robotic hepatectomy before and after ERAS protocol implementation in our program. With Institutional Review Board (IRB) approval, 609 patients who underwent robotic liver resection between 2013 and 2024 were retrospectively analyzed. A total of the first 65 patients were excluded to eliminate the impact of a learning curve. The remaining 544 patients were divided into 2 groups based on ERAS protocol use. Propensity score matching 1:2 was applied according to age, BMI, tumor size, tumor type, and extent of liver resection. Perioperative outcomes of pre-ERAS and post-ERAS groups were compared. Patients in the post-ERAS group more frequently had coronary artery disease (5.7% vs. 10.6%) and hypertension (5.7% vs 57%), whereas patients in the pre-ERAS group more frequently had heart disease (46.2% vs 11.1%). Estimated blood loss (EBL) decreased (214.7(150.0) ± 250.9 vs. 141.7(100.0) ± 151.5) in the post-ERAS group. A decrease in 90-day readmission rate was also observed in the post-ERAS group (22.6% vs. 13.4%). A propensity score-matched comparison of robotic hepatectomy outcomes before and after ERAS protocol showed improvement in perioperative outcomes, with lower estimated blood loss and fewer 90-day readmissions.