Robotic Liver Resection Safe Alternative to Open Surgery in HCC

Individuals with hepatocellular carcinoma (HCC) experience similar survival outcomes, with less perioperative morbidity, when they undergo robotic liver resection (RLR) rather than open liver resection (OLR), suggests a retrospective data analysis carried out by the Robotic HPB Study Group.

The reduced morbidity may expand “the potential number of patients able to receive treatment from which they are currently excluded because of the risk of liver decompensation,” write Fabrizio Di Benedetto, from the Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit at the University of Modena and Reggio Emilia in Italy, and co-authors in JAMA Surgery.

The researchers explain that the benefits of using a robotic platform during liver resection include increased stability, tremor filtration, magnified 3-dimensional vision, and instrument flexibility, which in turn permit gentle manipulation of the liver, precise dissection, and increased dexterity in narrow spaces.

Yet, the data on long-term oncologic outcomes of robotic surgery are sparse.

To address this, Di Benedetto and colleagues reviewed the surgical and survival outcomes of 106 patients who underwent RLR for HCC at the University of Modena and Reggio Emilia, University Hospital Zurich, New York-Presbyterian/Columbia University Irving Medical Center, or Weill Cornell Medical College between 2010 and 2020.

They were compared with 106 control patients, matched on the basis of clinical, oncologic, and technical criteria, who underwent OLR for HCC during the same period at an international referral center (Istituto Nazionale Tumori) for HCC surgical management with experience in nonrobotic, minimally invasive surgery.

The researchers report that although individuals in the RLR group had a significantly longer operative time than those in the OLR group (median, 295 vs 200 minutes), they had a significantly shorter length of stay in hospital (median, 4 vs 10 days) and a significantly lower rate of admission to the intensive care unit (ICU; 6.6 vs 19.8%).

People who underwent RLR did, however, have a significantly higher volume of estimated blood loss during surgery than those who underwent OLR (median, 200 vs 100 mL) even though they were significantly more likely to have a Pringle maneuver performed during surgery to stem blood loss (13.2 vs 1.0%).

There were no significant differences between the RLR and OLR groups in the number of patients requiring blood transfusions (n=9 in both) nor in the number of packed red blood cells units transfused (n=9 in both). Resection margins were also similar between the OLR and RLR groups (median 9 vs 8 mm).

Postoperatively, patients who received RLR were significant less likely to develop severe complications (Clavien-Dindo grade 3-4) than those who received OLR (2.8 vs 11.3%) and significantly less likely to experience posthepatectomy liver failure (7.5 vs 28.3%). The latter result is of particular importance when treating patients with cirrhosis who are at higher risk of liver decompensation after surgery, the investigators note.

The 90-day overall survival rate was comparable between the two groups, at 99.1% following RLR and 97.1% follow OLR, with cumulative incidence of death related to tumor recurrence a corresponding 8.8% and 10.2% at 24 months.

Di Benedetto et al comment that their study “is the largest Western series of consecutive patients treated with the full RLR approach for HCC.” They say the data show that “RLR is associated with better perioperative tolerability than OLR in patients with HCC.”

The team also points out that “reduced ICU and hospital lengths of stay as well as a lower incidence of severe complications may ultimately result in a reduction of overall costs and compensate for the higher technology-related expenses,” which are often criticized. The international nature of the study meant that it was not possible to carry out a cost comparison and cost-effectiveness analysis but Di Benedetto and colleagues say “intuitively, a median difference of 6 days of hospitalization represents a major saving for any hospital, as well as a 93.4% vs 80.2% rate of RLR and OLR patients, respectively, not requiring ICU admission.”

Also of Interest