Robotic versus laparoscopic liver resection:

propensity matched comparison of two-center experience

Emanuele Balzano1 & Lorenzo bernardi2, Raffaello Roesel2, Filippo Vagelli1, Davide Ghinolfi1, Giovanni Tincani1, Fabio Melandro1, Pietro Majno-Hurst2, Paolo De Simone1 & Alessandra Cristaudi2

Two referral centers for liver surgery:

1) Hepatobiliary surgery and Liver transplantation, University of Pisa (AOUP), Italy Robotic & laparoscopic procedures
2) Hepatobiliary surgery Unit, Cantonal Hospital of Lugano (EOC), Switzerland Laparoscopic procedures
Aim:
To compare the short-term-results of RLR vs. LLR in two referral
centers for liver surgery.
Methods:
Retrospective analysis of prospectively maintained MILS database
Two groups: RLR vs. LLR, stratified by difficulty level (IWATE criteria)*
Follow-up > 90 days.
Propensity score matching (1:1)
Inclusion criteria:
Elective MILS for malignant/benign indications (ITT)
Exclusion criteria:
*(In case of multiple liver resections, the resection with the
Hand-assisted procedures, Cyst’s fenestration, Non-elective surgery. highest score was considered for the difficulty index
Endpoint of the study: Non-inferiority of RLR vs. LLR
Conversion to open, operative time, blood loss Results:
90-day morbidity (CD) and major morbidity (CD ≥3)
269 patients included (RLR=77; LLR=192)
90-day mortality
RLR LLR
Surgery details RLR LLR Baseline (before PSM) (n=77) (n=192) p
Platform DaVinci Si/Xi
Age (years), mean (SD) 66 (12.1) 66 (12.0) 0.74
PSS when possible
Surgical principles
Cauliflower >> glissonean approach Male, n (%) 49 (63.6) 110 (57.3) 0.63
Parenchymal transection Crush-clamping CUSA
BMI (kg/m2), mean (SD) 26 (9.3) 25 (4.9) 0.03
Pringle According to surgeon preference
ASA score, median (range) 3 (1-4) 3 (1-4) 0.40
Surgeons All procedures by senior HBP surgeons
Previous abdominal surgery, n (%) 41 (53.2) 113 (59.0) 0.66
Learning curve MILS Included in the study period
Indication to surgery Case-by-case validation by weekly MDT Previous liver surgery, n (%) 8 (10.4) 17 (8.6) 0.72

Chronic liver disease, n (%) 62 (80.5) 88 (46.0) 0.008

Cauliflower technique Total nodules, n 87 312 0.045

(courtesy of Prof. B. Edwin, Oslo)
Nodules per patient, (range) 1.1 (1-2) 1.6 (1-12) 0.007

LLR
 Outcomes after PSM RLR (n=46) p Nodule diameter (mm), median (range) 24 (8-65) 25 (6-150) 0.30
(n=46)
Operative time, min. (ds) 236 (89.8) 227 (83.1) 0.64
Pringle time, min. (ds) 25 (23.9) 15 (25.2) 0.12
After PSM (1:1)
Blood loss (cc) 194 (108) 136 (66) 0.04*
Two cohorts, 46 patients each,
R0, n. (%) 44 (97.8) 44 (97.8) >.999
Balanced age, sex, BMI, ASA
Underlying cirrhosis (100%)
Conversion (%) 0 (0) 0 (0) >.999
Single HCC <5 cm diameter (93.5%)
Morbidity
Non-anatomical PSS, IWATE 1-2
Biliary Fistula n. (%) 2 (4.3) 0 (0) 0.46
Bleeding n. (%) 0 (0) 3 (6.5) 0.24
↓blood loss in RLR
LOS, days n. (ds) 6.1 (2.5) 6.1 (2.5) >.999
Trend toward longer Pringle in LLR
90-day Mortality 0 (0) 0 (0) >.999 No difference in other endpoints
Conclusions:
RLR is non-inferior to LLR.
↓blood loss in IWATE 1-2 RLR for single HCC of <5 cm with cirrhosis.
Call for prospective studies of RLR vs. LLR in IWATE 3-4 resections.
 Introducing minimally invasive liver surgery (MILS) in a tertiary center of Southern
Switzerland:
Reappraisal of the first 100 consecutive cases
Lorenzo Bernardi & Raffaello Roesel, Sotirios-Georgios Popeskou, Alice Vanoni-Colombo,
Fabio Garofalo, Dimitri Christoforidis, Pietro Majno-Hurst & Alessandra Cristaudi.
Department of Visceral Surgery, Cantonal Hospital of Lugano,
Department of Biomedical Science, Università della svizzera italiana (USI)

Background:
MILS program was implemented at our center in January 2015.
LLR introduction 2015-2022

Objective: Safe introduction of MILS.

Methods:
Retrospective analysis of consecutive LLR since MILS
34 34 34

31

introduction,
27

21

Comparative cohort: consecutive OLR from the same period,

19
19 18
16 23
11
3

LLR stratified as per difficulty level (IWATE criteria),

12
10

18 16 16
15 15

Cyst fenestrations excluded.

10
9 11

2
2015 2016 2017 2018 2019 2020 2021 2022

Endpoints: Conversion to OLR, operative time (OT) blood loss, OLR LLR All

90-day morbidity (CD), 90-day major morbidity (CD ≥3), R0, OLR LLR p
Surgery details N=100 N=100  
90-day mortality.
Results: 100 LLR and 100 consecutive OLR were included. Wedge resection, n (%) 36 (36) 53 (53) 0.13

OLR LLR Sub-segmentectomy, n (%) 9 (9) 5 (5) 0.30

Baseline N=100 N=100 p
Segmentectomy, n (%) 7 (7) 10 (10) 0.50
Age (years), mean (SD) 64 (11.3) 65.4 (12.2) 0.40
Bi-segmentectomy, n (%) 22 (22) 19 (19) 0.67
Male, n (%) 58 (58) 53 (53) 0.70
Major hepatectomy, n (%) 26 (26) 13 (13) 0.06
BMI (Kg/m2), mean (SD) 24.8 (4.6) 25.2 (4.4) 0.53
Pringle’s maneuver, n (%) 72 (72) 81 (81) 0.13
ASA score, median (range) 3 (1-4) 3 (1-4) 0.83
Pringle time (min), median (range) 56 (5-100) 45 (10-235) 0.8
Previous abdominal surgery, n (%) 82 (82) 72 (72) 0.54
OT (min), median (range) 475 (225-870) 315 (120-1000) <0.01
Previous liver surgery, n (%) 30 (30) 11 (11) 0.007
Conversion, n (%) - 12 (12)  
Chronic liver disease, n (%) 13 (13) 29 (29) 0.024
Intraoperative transfusion, n (%) 3 (3) 4 (4) 0.71
Total nodules, n (mean) 281 (2.8) 168 (1.7) 0.003
Blood loss (ml), median (range) 300 (50-1500) 200 (50-2500) 0.01
Nodules per patient, median (range) 2 (1-13) 1 (1-7) <0.01
Nodule (mm), median (range) 25 (5-210) 24 (7-150) 0.93 Difficulty level (IWATE criteria)  
OLR LLR Low Intermediate Advanced Expert
p p
Outcome LLR (n=100) (n=31) (n=35) (n=16) (n=18)
N=100 N=100  
Pringle’s maneuver, n (%) 23 (74) 30 (86) 14 (87.5) 14 (78) 0.97
LOS (days), median (range) 9 (4-102) 6 (2-21) <0.01
90-day morbidity, n (%) 43 (43) 21 (21) 0.02 Pringle (min), median (range) 45 (10-93) 45 (10-210) 45 (20-185) 40 (10-235) 0.11

Biliary fistula, n (%) 12 (12) 7 (7) 0.27 OT (min), median (range) 240 (120-540) 280 (145-590) 410 (225-750) 550 (130-1000) <0.01
Major morbidity, n (%) 23(23) 6 (6) 0.003
Conversion, n (%) 1 (3.2) 3 (8.6) 1 (6.2) 7 (39) 0.015
Mortality, n (n%) 1 (1) 1 (1) 1.0
OLR LLR Intra-op transfusion, n (%) 0 (0) 0 (0) 1 (6.2) 3 (17) 0.40
Histology: p
N=100 N=100   Blood loss (ml), median (range) 200 (50-800) 200 (50-1000) 250 (100-1500) 400 (100-2500) <0.01

CRLM, n (%) 56 (56) 39 (39) 0.15 LOS (days), median (range) 5 (2-21) 5 (3-18) 7 (4-15) 9 (6-17) <0.01
HCC, n (%) 10 (10) 27 (27) 0.01
90-day morbidity, n (%) 6 (19) 5 (14.3) 3 (18.7) 7 (39) 0.44
CCA, n (%) 10 (10) 5 (5) 0.21
90-day major morbidity, n (%) 0 (0) 0 (0) 2 (12.5) 4 (22) 0.50
Benign, n (%) 2 (2) 10 (10) 0.02
Other, n (%) 22 (22) 19 (19) 0.67 90-day mortality, n (n%) 0 (0) 0 (0) 0 (0) 1 (5.5)  
January – March 2022:
R0, n (%) 83 (83) 95 (95) 0.51
Conclusions: R0, n (%) 9/1233LLR,
31 (100%) (94%)PSS = 100%
15 (94) 15 (83) 0.98
Conversion = 0%
Laparoscopic liver surgery was implemented safely.
Morbidity = 11%
Difficulty of LLR is correlated with intra- but not post-
Major morbidity (CD ≥3) = 0
operative outcomes and R0 rate.
Hospital stay (median) = 3 days.