Stepwise implementation of robotics and a certified enhanced recovery program significantly improves multiple outcome...

Minimally-invasive surgery (MIS - including laparoscopy and robotics) and enhanced recovery after surgery (ERAS®) programs reduce complications and improve functional outcome for cancer patients. Their combined impact on liver surgery cohorts remains unclear.

This Austrian single centre cohort study assesses the stepwise implementation of laparoscopy, robotic-assisted-surgery (RAS), and an audited ERAS® certification. Three periods (17 months each; January 2020 to 06/2024) were compared: P1 (pre-RAS/pre-ERAS®), P2 (RAS/ERAS®-like), and P3 (RAS/ERAS®). Outcomes included intensive-care and overall length-of-stay ((ICU-)LOS), 90-day-morbidity, mortality, post-hepatectomy liver failure, haemorrhage (PHLF/PHH), and bile leakage (BL). Textbook outcome after liver surgery (TOLS) was evaluated in cancer patients (definition: no blood loss >1000 ml, MIS-conversion, PHLF/BL, severe morbidity/mortality, readmission, and R1-margin).

Over the three periods n = 225 patients showed comparable demographics, underlying liver disease, preoperative chemotherapy, and major resection rates. MIS (RAS) increased from 31.1 % (0 %), to 71.1 % (52.6 %), and 77.3 % (45.6 %; p < 0.001), with less conversions (21.1 %, to 3.7 %, and 5.9 %; p = 0.030). Decreasing median blood-loss (400 ml-200 ml in P3; p = 0.002) led to low transfusion rates (P3: 5.7 %). Median LOS/ICU-LOS decreased from 9/3 days, to 6/2, and 5/1 days (p < 0.001), overall (severe) 90-day-morbidity from 54.1 % (29.5 %), to 39.5 % (14.5 %), and 35.2 % (14.8 %) (p = 0.022/p = 0.011). PHLF reduced from 13.1 %, to 1.3 %, and 5.7 % (p = 0.009). TOLS rates enhanced from 37.9 %, to 68.2 %, and 70.8 % (p = 0.002). MIS was an independent predictor of lower (severe) morbidity and LOS.

Implementing MIS/RAS and ERAS® in an established hepatobiliary unit significantly improves blood-loss, (ICU-)LOS, morbidity, and PHLF. This ultimately leads to substantially increased TOLS rates in common oncological indications.