Live-streaming robotic liver resection for surgical education: is it safe? a multicenter matched cohort analysis

Live-streaming surgery is increasingly used as an educational tool in the surgical community. The safety of live-streamed robotic liver resection has not been formally evaluated. We assessed perioperative outcomes of robotic live-streaming liver resections compared with not-live streaming liver resections. This multicenter retrospective matched cohort study reviewed 311 liver resections performed between October 2024 and December 2025 at three European HPB centers. Forty-two consecutive patients who underwent robotic live-streaming liver resection (L-SS group) were matched 1:1 to patients who underwent not-live liver resection (not-L-SS group) during the same period, generating a matched cohort of 84 patients. The primary endpoint was the rate of severe complications (Clavien-Dindo ≥ III). Secondary endpoints included conversion to open surgery, intraoperative blood transfusion, postoperative bile leak, posthepatectomy liver failure, length of hospital stay, R1 resection rate, and 90-day mortality. Intraoperative variables, including use and duration of the Pringle maneuver, were also recorded. After matching on ASA score, presence of cirrhosis, tumour laterality, lesion contact with the cavo-caval confluence, and surgical approach, baseline characteristics showed reduced imbalance between groups, although the L-SS group retained significantly larger tumours and a higher proportion of technically advanced resections. The primary endpoint, severe complications (Clavien-Dindo ≥ III), was similar between groups (4.8% vs. 7.1%, p = 1.000), as were conversion rate, transfusion rate, bile leak, posthepatectomy liver failure, readmission, reintervention and 90-day mortality. The L-SS group had a significantly higher frequency (83.3% vs. 48.8%, p = 0.001) and longer duration (median 45 vs. 25 min, p = 0.004) of the Pringle maneuver, a shorter hospital stay (7 vs. 10.5 days, p = 0.001), and a lower rate of any-grade 30-day complications (7.3% vs. 33.3%, p = 0.005). These findings were unchanged after excluding patients with a Pringle maneuver duration exceeding 60 min (sensitivity analysis). In this multicenter matched cohort study, robotic live-streaming liver resection did not detect an increase in severe postoperative complications in highly selected patients, with severe complication rates comparable to non-streamed resections. The higher Pringle maneuver use likely reflects a didactic intraoperative strategy rather than increased risk. Prospective studies should evaluate educational efficacy and trainee skill acquisition.