Does complexity compromise outcomes in robotic hepatectomy?

Complex hepatectomies are challenging procedures in minimally invasive liver surgery. While the feasibility of complex laparoscopic hepatectomies is widely accepted, there is still limited data using the robotic platform for technically difficult cases. This cohort study evaluated postoperative outcomes in high and low complexity resections.

Patients undergoing robotic hepatectomy recorded in a prospective database between 2020 and 2024 were included. Outcomes were compared between resections with a high complexity (HC) and low complexity (LC) based on the IWATE difficulty score system. Factors associated with severe morbidity were explored using logistic regression analyses.

Of 237 patients with a median age of 64 years (interquartile range 55-71), 125 patients had HC and 112 patients had LC resections. In the HC group, segmentectomies (n = 40, 32%) were the most frequently performed resections compared to non-anatomic hepatectomies (n = 97, 87%) in the LC group. The overall rate of postoperative morbidity was comparable between groups (comprehensive complication index 12.3 (standard deviation (SD) 21.6) vs. 7.5 (SD 17.6), P = 0.061), while operating time, blood loss, and rates of severe morbidity were higher in the HC group. There were no significant differences in achieving textbook outcome between groups (n = 88, 70% vs. n = 90, 80% P = 0.077). Major hepatectomy was identified as the sole independent risk factor for severe morbidity (OR 2.670, 95%CI 1.010-7.070, P = 0.048).

Complex robotic hepatectomies are safe and feasible in high-volume centers with high rates of achieving textbook outcome.