Navigating Complexity: Advances in Robotic Hepatectomy Outcomes

A multicenter study shows complex robotic hepatectomy is feasible and safe at experienced centers, delivering high textbook-outcome rates despite greater operative burden in higher-complexity cases. Clinically, the practical message is clear: high-volume programs with seasoned robotic hepatobiliary teams can attain acceptable morbidity and oncologic margins for technically demanding resections, supporting robotic approaches for carefully selected complex cases in those centers.

Robotic platforms were once seen as offering limited advantage over laparoscopy for the most demanding liver resections; this cohort shifts that expectation. Three-dimensional visualization, wristed instruments, and improved ergonomics translated into better operating precision and expanded opportunity for parenchyma-sparing strategies in difficult anatomy. The report emphasized that these platform strengths enhance safe dissection around vessels and bile ducts but do not replace surgical experience, and they now more directly inform operative planning, including use of intraoperative navigation and targeted exposure techniques.

In a multicenter cohort of 237 patients (125 high-complexity, 112 low-complexity), prespecified primary endpoints included textbook outcome, conversion to open surgery, and severe morbidity, with detailed intraoperative and 90-day postoperative reporting. Headline results: overall textbook outcome 75% (70% high-complexity vs 80% low-complexity, P = 0.077); conversion to open surgery in 14 patients (6% overall; 7% HC vs 5% LC); and higher severe complications in the high-complexity group (23% vs 11%, P = 0.015). Operative time and blood loss rose with complexity (median operative time 243 min HC vs 164 min LC; median blood loss 400 mL HC vs 250 mL LC, both P < 0.001), while R0 resection rates remained high and comparable. Higher IWATE complexity correlated with longer operations, greater blood loss, and increased severe morbidity but did not meaningfully raise conversion rates.

On multivariable analysis, major hepatectomy was the sole independent predictor of severe morbidity (OR 2.67, 95% CI 1.01–7.07, P = 0.048), distinguishing extent of parenchymal loss from other complexity metrics as the primary driver of adverse outcomes. The IWATE score correlated with intraoperative measures and remains a useful framework for anticipating technical difficulty and guiding preoperative planning, but it was less predictive than the actual extent of resection for postoperative severe morbidity. Clinicians should therefore weight parenchymal loss heavily when selecting patients and planning perioperative care.

Key Takeaways:

• Complex robotic hepatectomy is feasible and frequently safe in experienced centers, with a 75% textbook-outcome rate overall.
• Higher IWATE complexity predicts longer operative time and greater blood loss and is associated with increased severe morbidity, although conversion rates did not significantly increase.
• Major hepatectomy—not the IWATE score alone—was the independent predictor of severe morbidity; prioritize assessment of parenchymal loss when planning high-complexity robotic resections.